GW1-2022-10305_Well Construction - GW1_20221114

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ell
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C eliGontraetortrertificationNumb= 15.OUTER CASING for multi=rased wells ORLINER ifs licable
YADKIN INEL 1 COMPANY,INC,
FROM Ta I I DIAMETER I TEXCOMS MATERIAL ~
Gomp�YName 16.INNIR CASING OR TUBING eothermal closed-loo
y:Well Construction Permit#: �� FROM To DIAMLrrER THLCI ESs MATmaAL
permits ` ry, ) fL g� is G! in. 0190t PVC-
"' L)s!all applicable well construction r,e.U1C,Coon Slate,Variance,eta
3.Well Use(check well use): % in.
17.SCREEN
Water Supply Well: .FROM TO DIAMETER SLOT SIZE TLUCfOVLss MATERIAL
❑Agricultural ❑Municipal/Public ft. tt. in.
❑Geodiernral(Heating/Cooling Supply) AResidential Water Supply(single) . g• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO1 MATERML ECMPLACEMENTATETHOD&AMOUNT
Non-Water Supply Well: ft, t7�� ft. �406 Ptv P UCt.A t3 6
❑Monitoring ❑Recovery it tr
Injection Well: ft % (' 1•
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK des livable
❑Aquifer Storage and Recovery ❑Salinity Barrier f!i
To MATERIAL EA�LACEMENTMETHOD
❑Aquifer Test ❑Strnmwater Drainage fL
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIMON color,hardness,soiVmek 4 sin sae,etc
❑Geothermal(Heatinp�CoolingRetum) ❑Other(explain under#21 Rem ark5) D g• 10 IL S•D�,�
p .s
4.Date Well(s)Completed: I U « 3� Well ID# L - `�7'� `70 ft �1;?ft G can i
5a.Well Location:
Phone # ft, ft.
.? �F 4
w�.r g�6 B4 rr ft ftFanility/Owner Name Facility ID9(if applicable) ft' ft E f
' S1�i� ��k eve. �� • fr. ftNOV 1 Physical Address,City,and Zip 16VA"Is c'♦ Pe- gau Le it ft .
2022
2x.REMARKS —'Z
JA s�� DWQIBOG
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification.
N kl 2� .�i! W
6.Is(are)the well(s):Aermanent or ❑Temporary of Crtified Well Contractor Date
Signs
By signing thisfonn,l hereby cer(o that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards and that a copy
If this is a repair,fdl out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under f21 remarks section or on the back of this form. 23.Site diagram or additional well details: `
B.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 C>:W-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: l 24.SUBMITTAL iNSTRUCTTONS
9.TotaI well depth below land surface: G�`1 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1fdfferent(example-3@200'and 2©100) i
�0 (ft) 7Aa. For All WeiLs: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: S. 7 24b.For Iniection Wells: Copy.to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
` Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ' Method of test: �lW �la1V
70%HTH OZ DATE SITE VISITE[
13b.Disinfection type: Amount:
VISITED BY: VIB' °4,J4
o arolina Deartment of Environmental Quality-Divisinn of Water Resources;