GW1-2022-00185_Well Construction - GW1_20221216

'b' 1L1�, CONSTRUCTION�(CO� f�`�-1� For Internal Use Only:
1.Well Contractor Inforrantion:
/��°P !)1`✓ 1 WATER 5
NC
FROM
TO DMCRIP17QN
Well Conhaotoi �ayme [� n— -�. tt. g.
a 5 J --Ay^`F1�
?� M
NC Well Contractor Ccrt c;eEonX=ber 15.OUTER CASING-.for multi-cased wells ORLINER rf a livable
D r L 1 • 2022 FROM TO D14MRTER TMCKMS MATERIAL
YADKIN WELL COMPANY,INC,
ft. ft. in.
Company Name 16.RUNNIER CASING OR TiJBTNG eothermal closed-loop)
2,Well Construction permit#: �1 (c a q FROM TO DIAMETER TEICKNESS 11YATEIt7AL
LWall applicable well construction permits(i.e UIC,County,State,Parlance,ew.) fL ft ®o�� in. V
3.Well Use(checkwell use): ft. ft. in.
�-+
17.SCREEN
Water Supply Well: FROM TO DfAMrrrrrt slATSIZE THICiC1IESS MATERIAL
❑Agricultural CMunicipal/Public ft. ft, l"
❑Geothermal(HeatinglCooling Supply) ukesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
[:]Irrigation Owens>100,000 GPD FROM I To MATERIAL I E0LACEMMT1%4ETHOD&AMOUNT -1
Non-water Supply well: C) it. ®' ft. eo-r_b, 5' Ov
❑Monitoring ❑Recovery /® fL �v ft. 3Q�.s'l(Oi r
Injection well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL FZTPUCEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft 6
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) []Tracer 20.DRULTNGLOG attach additional sheets necessaryl
FROM TO DFSCRIMONi color,hardness,solllrock sar,eta
❑Geotbermal(Heating/CoolingRetlnn) ❑Other(explain under#21 Remarks) ft. �8 e ft- y�
4.Date Well(S)Completed-jx- 2- Well ID# ',S�f .q ft S� ft G1 SO'L
5a.Wen Location: p� Phone #3�G� �3m d�s C� � 7?' ft'fL
�a�iv�r✓1 Q® ' ib— /a n r! 7,f/� ft //40 Sof� eelo�P�yarda•
Facility/Ownerm
Nae Pacili1yID9(if applicable) I f s}
Physical Address,City,and Zip ft ft
21.REMARICS
Q_M
County Parcel Identification No.(FIAT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell$eld,one lat/longis sufficient) 22.Certification: C l
6.Is(are)the well(s): 11dermanent or ❑Temporary SignagjW of Cartififil Well Contactor Date C J
Bysigningthlsform,lherebycertyythatthewell(s)was(were)comiructedinaccordancewith
7.Is this a repair to an existing well: ❑Yes or [% o 15ANCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repolr,fill out known well construction information and explain the nature of the of this retard has been provided to the well owner
repair vnder#Zl remarks section or on the back of thisform. 23.Site diagram or additional well details:
8.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 GW-1 is needed. Indicate TOTALNUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled• 24.SUBA=AL INSTRUMONS
9.Total well depth below land surface: (fL) Submit this GWA within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3()a 200'and 2@1001
a
®� 24a, For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Uiiit;1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
( ) Bit Off. 4.050 34b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.Forwater Supply and Open-Loop Geothermal Return Wells:Copy to the OI
(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 V
� p }�� Permit Program,1611 MSC,Raleigh,NC 27699-1611 �C
13a.Yield(gpm) r sJ Method of test: �r�b 0
OZ DATE SITE VISITED: ®
70%HTH
13b.Disinfection type: Amount:, l®� ,' p�a '
VISITED BY: Ja°a,9 �