GW1-2022-00165_Well Construction - GW1_20221219

o L CONS'TRt i()C'TION RECORD fGW-1) For internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Cwhactnr me :ROM TO DLSCInPTION �
ft. ft.
NC Well Contractor CrtiScatiomNomber 2 P,
M OUTER CASING for malfi- sedweIb ORLINER fa GuhIe
YADKIN WELL COMPANY,INC. FROM Tr DtMarER THIf3'tnlss MATERIAL
Company Name 1
/'�
, I 16.PWER CAMG OR TUBING eotharmal closed-too
2.Well Construction Permit#: N I(..II� FROM TO DIAMEIaR I MATERW,
List all applicable well mnamr.11on permits(ia UIC County,State,VaHanm,etaJ r R 5—7 R in. a/G
tYch Use(check well use): R I ft.
'up1Y 4Vell: 17.SCREEN
FROM I TO DIAMYlER SLOriM—E I TRImOYass MATERIAL
I LL .lecltaral DMunicipal/Public ft.
I LGcoth.mal(Heating/Cooling Supply) Asidential Water Supply(single)
❑Industrial/Commercial DResidential Water Supply(shared) 19.GROUT
Dlnigation 0Wells>100,000 GPD FROM TO MATH[uAL I EMFLACLT1ENTafE'rHOD&AMOIMI'
Non-Water Supply Well: ft. R
DMnuitoring ORecovery ft R
Injection Well: R R
➢Aquifer Recharge OGroundwater Remediation 19,SAND/GRAVEL PACK da tirahle
DAgrd$r Storage and Recovery OS&Iiaity Barrier FROM To I BMIACfi NTMETHOD
➢Aquifer Test OStormwater Drainage R R
DBxpermm®tal Technology DSubsideace Control ft ft
OGeotheraal(Closed Loop) ➢Tracer 20.DRII.LL4G LOG fails additional aheeb if necessary)
DGeothermal(Hcatiug1Coolmg RebnD) DOther(explain under#21 Remad(a) FROM TO DISCIUMON mlar hnraaer'Wllraek .in 1n,
7�t /4/vf'
4.Date Well(s)Completed: - 3-a2-weum#,A4-)'-o R R r'e anti
R R
Sa.Well Lo�eajyp_tt,.SN 1Phone #-%7�laf 3.?D-[�5 ft. R o�
Fee]iq/O.+aaNeme Facility IDM(dapplimble) R ft' A� �0�� Ob — fl-
Fa meal Addresa,City,and Tip f�/� oV —xic- 3a
40i/.6t.[>_Y 1 T` 21.REMARKS —
Coney Parcel Mautification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:well field.field,one kVlongis sufficient) 22.Certification:
i o 5aX 50 N S! !'Sr 34,Z7 W
6.Is(are)thewell(s): Permanent or ➢Temporary of Geftificd Well Contractor Date
Bys/gnvrg thtrform,I hertby ttrnJy Ihol the
well(s)
coos(were)con0mctedM amnrdanre with
7.h this a repair to an existing well: e8 )or a{{11 CY 15A NCAC 02C.0(00 or ISANCAC 02C.0200 Well Conshmcrion Standards and that a ropy
i1 this is a repair,fdl Out Imown well cons6ucn'o rnalion and¢plain the r6fure of the of this retard has been provided to the well owner
repair n der$21 remarks section or on the back ofthisfarm. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Clased-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
coutnmtton,only 1 GW-I is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also atlach additional pages if neownary.
drille Z 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Q� (ft)
For multple wells list all depths ifdr$erent(emmple-3(a)20 andI�100) Submit this Gw-1 within 30 days of well completion per the following:
l�pd�? 242. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of teeing:_ (ft)Ifnvater level is above casing,vx"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
_
Bit Off: S•�O�:S 24b.For IDieetion Wells: Co to D
11.Borehole diameter: _(in.) WR,Underground Injection Control(fUC)
Prograrq N 1636 MSC,Relcigb,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Oaen-Loan Geothermal Return Wells:Copy to the
(tc auga,mtecy,cable,direct path,etc.) county environmental health deparom'at of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD: Copy to DWR,C_C_PCUA
7 t Permit Program,1611 MSC,Raleigh,NC 27699-1G"-- - - - --
13a.Yield(gpm) A Method of test:
13h.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED:
Pri re" 'NISIV
DBY: 4z --_