GW1-2022-10314_Well Construction - GW1_20221114

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E1 LH 47I�T�1 JT�TfJ� I RECORD CORST'9 M_V-1 For Internal Use Only:
1.Well Contractor information.,
ZONES
FROM TO ]DESCRIPTION
Well Contractor e r ft ft,
�41,eft• �l�` ft /© r �i1�
NC Wall Contractor CertificadanNumba 15.OUTER CASING•forsriulti-ca ed wrlls ORLINER rf a liable
YADKIN WELL COMPANY,INC. FROM To nrAMETEFt THICIINESS MATERIAL
p� ��._ ft. ft in.
Company Name r,.p j-jlkk � �� 16.IlVNER CASING ORTUBING eothermalclosed-loo
2.Well Construction Permit#: 2 ® FROM TO DIAMEMM THICIaMSs I MATERIAL
List all applicable well construction permits(i.e.UIC,County;Ztate,Yarianca,etc) 4-/ /(3,. lam in. 4�
3.Well Use(checkwell use): - ft ft m
17.SCREEN
Water Supply Well:
PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
i�gacultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) E Ksidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO• MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft. 3C11..tyry�c. �0 6_<
❑Monitoring ❑Recovery it �° ft. fl:, ,. •,R
Injection Well:
ft. % �-
❑AquiferRecharge ❑GrmmdwaterRemediation 19 SAND/GRAVEL PACK ria liable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL Ell LACEMENTMETHOD
❑Aquifer Test ❑Storruwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DR UNG LOG attach additional sheets if necessa
❑Geothermal(Heating/CoolingRetum FROM TO DESCRIP'1TON color,hardness,soW=k Type,grain she,etc) ❑Other(explain under#21 Remarks) tf
Ty e ft. �0'
4.Date Well(s)Completed:10-0A,d)- WellID#� P_ �'7 � a� ft' iee
5a.Well Location: Phone # �, ` �_, ,2?�' ft
Z 9
ft
Facility/OwnerName PacilifyID#(ifapplicable) ft. ft
Physical Address,City,and Tdp 6� ft ft. NOV A 2022
21.REMARKS Linh
County Parcel Identification No.(PIN) E' '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lattlong is suificieat) 22.Certification:
W 2-Y' �k,2,r w
6.Is(are)the well(s): l�eermanent or ❑Temporary Signaplio of Cartificd Well Contractor Date
By signing thisform,I hereby certs)�that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L "o ISA NCAC 02C.0100 cr 1SA NCAC 02C.0200 Spell Construction Standards and that a copy
If this is a repair,fill out known well construction information and erplafn the nature of the of this record has been provided to the well aw»er.
re
.Pair #ZI remark section or on the back ofihisform.
23,Site diagram or additional well details:
8.For Geoprobe/DPT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarla Box).You may also attach additional pages if necessary.
drilled: ed 24.SUBMITTAL INSTRUCTIONS
B
9.Total well depth bel6w land surface: (ft) Submit this GW-1 within 30 days o£well completion the following:
Far multiple wells list all depths ifdifferent(example-3 c@200'and2©100) y p per
5160 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaler level is above casing,use"+"
11.Borehole diameter-. (in.) Bit Off: �°Cl &0 24b.For Xieetion 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 e
(ie,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY ryWELLS ONLY: f, 24d.For Water Wells producing over 100,000 GPM: Copy to DWR,CCPCUA
�f!Y+ Method of test: /�a G' a9 Yl�� Permit Program,1611 MSC,Raleigh,NC 27699-I611 �� q
13a.Yield(gpm) (�
70%HTH r�e�j OZ DATE SITE VISITED: Ft"O�o L VA.%a
13b.Disinfection type: Amount: Vo+
VISITED BY: to
arolina Department of Fnvirnnmen ial 0aali tv-Divicinn of Watrr R ecnnrnrc Revised 6-6 Z018