GW1-2022-10439_Well Construction - GW1_20221116

WELL C ONS RUC 1TION RECORD (GN-V-i1) For Internal Use Only:
s Well contractor information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contrac or Name
O - 4 3� ft.
(�
ft. ft
NC Well Contactor Certification Number 15.0TR CANG formsed wells reblelMFROM RffiR MATE RIAL
YADKN WELL COMPANY,INC.
Company Name + I I 9 ft. r�7S in-
.09-91 C
Yet 1 ctc�y 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit FROM TO DIA ETER TMCIOVPSS TATERIAL
List all applicable Hell construction permits(Le.MC,County,State,Variance,eta.) ft- ft in.
3.Well Use(ebeckwell use): It ft' in.
Water Supply Well: FROA�REErTO DIAMETER sLOTSTLE THICIOYESs MA TER IAL
❑Agricultural ❑ Icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) @fesidental Water Supply(single) ft. it. in.
❑Industial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD 4 AMOUNT
Non-Water Supply Well: ft. ft. CGtlj�f Jwk rt-, 1aG•C-
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation w
19.SAND/GRAVEL PACK ff applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. C
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FRO
❑Geothermal(Iieating/CoolingKcllar) ❑Other(explain under#21 Remarks) M To DESCP-TMOx color,hardnesz,seiurocx .n rce,cm
�f�j. ft �
ft' e i S TO
4.Date Wells)Complete,06 e1 ytooa Well ID# A -�3 ft• 7 4 ft
® O " �rsw + � ; LJ
5a.Well Location: Phone '71 ft "I f 1?ie
`� 1/ y P!�I�l'Y� 9 ft fat. ft. I� �t a e
Facility/Owner 14ame Facility 1D#(tf applicable) 1 dQ IL 041 fL It f l Y
2C11 c. Bu� ArDi- MI! F�J-�-C�x,S ft. fc ;
Physical address,City,and
ft ft 2_02?
A ( ' ( 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2aCerfiflcaN
6.Ls(are)the well(s): iw' rmanent or ❑Temporary of Certified Well Contactor Date
By signing thisform,1 hereby certjfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or QNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200!Pell Construction Standards and that a copy
If this is a repair,fdl out!mown well construction information and erplaht 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:
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 o yVjr is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /* u 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L —(ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(erampie-3Q200'and 2@1 M
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"+" / G
11.Borehole diameter: `�' ( '�-5' (in.) Bit Off: Cam•a 0 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) C
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: ^ 141.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) (b Method of test: V
I// Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: &!— - 2 Z
Uri re- —
VISITED BY: 0&2__