GW1-2023-00775_Well Construction - GW1_20230112

For Internal Use Only:
1.Well Contractor lnforruntion: GOA
14.WATER ZONES r
FROM TO DBSCRIPTION
F7ol]Coa`tr�actor Name FROM
a S-0 2 V•
0364
NC Well Contractor Certification Number
15,OUTER CASING for mvlti-cased wells ORLTNER rf a liEMATrWAL
YADKIN WELL.COMPANY,INC. FROM -Ta O Tess
Company Name ��
`� 3qrF 16,INKM CASING OR TUBING( eothermal closed-loop)2,Well Construction Permit#: 2-02•( 06� FROM TO DIAMETER TMCM%MSS List all applicable well constructionpermits(Ge,illC,County,State,Parlance,eta) M ftiv G >/
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO ,DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M c��unicipal/Publi ft, to.
❑Geothermal(Heating/Cooling Supply) t�Residential Water Supply(single) ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO MATERIAL MaLACEMENTMET60D&AMOUNT
Non-Water Supply Well:
OMonitnring l7Recove#y �� t_' fL ft Si
lujection Well: 1l
ft. %
❑A uffer Recharge ❑Groundwah- edi on n
HIV 2`'23 19-SAMIGRAVELPACKErd-DRIcabio
❑Aquifer Storage and Recovery ❑Salinity Barner FROM TO-. MATERIAL EMPLACr=NT D
❑Aquifer Test ❑5tbrrr}�vater;l)Xair�agc;:.: •:� ,.;i t ft ft_
❑Experimental Technology ❑Subsidence Confr YQiDIOG ft it
. r
❑Geothermal(Closed Loop) ❑Tracer 20,DRMIMgGLOG attach additional sheets ifneemsary)
❑Geothermal(Heating/CoolingRetum) OOther(explain under#21 Remarics) FROM To DFZCRIMON solar hardness,saiVrock e, ,in sue,ate.
p Q ft. ft. a �'
4.Date Well(s)Completed: !' �s Z'WeII17 : — (f R
dd4ML �T� 4vf�ie
5a.Well Location. P One _• V pp
Facility/OwnerName Faci]ifyID#(ifUpficable) ft ft
��•�y�
O.Ai ��L L` e"/i g ft it
f'O%`lam.
Physical Adclress,City,and Zip ft. I R•
yL RRNL41M
Cotarty Parcel Identification No.(PIN) % �+ 105,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9� of "au &w C0 - 7C
(ifwall field,one latllongissufficient) 22.Certification: R4-0 lvwl'o /a^D.' JQ`-00
6.Is(are)the well(s): dermanent or ❑Temporary Signature of Certified Well Contractor, Date
� / By signing thisform,I hereby certify that the well(s)was(were)constructed in awordance with
7.Is this a repair to an existing weII: ❑Yes or L� o ISA NCAC 02C.0100 or I5A 11=02C.0200 IPell Constructian Standards and that a copy
Ifthis is a repair,fdl out]mown well construction information and explain the nature ofthe ofthis record has beenprovided to the well oxvner.
repair under#21 remarks section or on The back ofthis 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,only 1 GWr l is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlm Box).You may also attach additional pages ifnecessary. '
drilled:, L r� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /L9 ll�9 J (fL)
For multiple wells list all depths Ifdiffereni(ecample-3()a 200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 (ft-) Inf'rmation Processing UA 1617 MSC,Raleigh,NC 27699-1617
ifwaier level Is above casing,use/ (♦
v
11.Borehole diameter: (�) Bit Off: LY b � 24b,For Irliection Wells: Copyto DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.WelI construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,eta.) county environmental health department of the county where installed �(
FOR WATER SUPPLY WELLS ONLY:
24d.For Water WeIIs producinla over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpni)
�� Method of test: �� /,pJ� Permit Progrdm,1611 MSC,Raleigh,NC 27699-1611 rxb A
70%HTH y oZ DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY: �r