GW1-2021-01157_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD (GW-1) car intern I Use Canis-:
1.Well Contractor Information:
14.VVAT1rR ZONES - -
Well Contractor kame ` FRORI TO ! d iSCu trT[Oid ! t®
1 _
n i k
NC Well Contractor Certification Number 15.OUTER CASING(for rrirdtl-6sed scells)Olt LINER'(if a lieable '
YADKIN WELL COMPANY,INC. °; FROM TO DIAP:IETER ! THICKNESS rvLa,�Raaa �q
ilre., r_.
Company Name
16.INNER C:#S11°1G Olt T iiIJIP1G(geotirerratal closed-loo )
2.Well Construction Permit# f f1�L d®tA%ao 33 71 FROM TO DIANIETER THICKNESS 14IATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. I in.
3.Well Use(check well use): ft. "' I in.
Water Supply Well: 117.SCREEN
FROM TO vtAi aETER SLOT SIZE TIUCKNESS MATERVAL
❑Agricultural ❑Municipal/Public ft. a. !in.
❑Geothermal(Heating/Cooling Supply) 11Cesidential Water Supply(single) ft, R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ill GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATEPIAL ! EMPLACEMENT 14IETHOD&AMOUNT
Non-Water Supply Well: b ft° 4/ ft. I&®I�Gh•• J L" �4
❑Monitoring ❑Recovery t it. a t, It.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(il'aya,le aLL+)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM[PLACEIVIENT M[ETHOP
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(atiach additional sheets if necesiaiy)
FROM TO DESCRIPTION(color,hardness,soittroctc type,°rain size,etc.)
❑Geothermal(Heating/Coolingrteturn) ❑Other(explain under#21 Remarks) ft ft
i
4.Date Well(s)Completed: 9-14"a024 Well IIlD11
5a.Well Location: 11 Phone # ft. ft.
RCAs't�'�1 LQU�Ii r- ft. ft.
Facility/Owner ame Facility ID#(if applicable)
ft. ft.
14!A P0 lG�r SP r'-et5 LL
Physical Address,City,and Zip
C' ft. ff.
C v r r!l 21.REMARKS (�
County Parcel Identification No.(PIN) eX.'A uve'I '-qcW COY/t3JC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ®v pne0.s�� Cyr`�t1
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): ❑Permanent or ❑Temporary Si ure of CcrWicd Well Contractor Date
By signing this form,1 hereby certify that the we/l(s)was(were)constructed in accordance wiih
7.Is this a repair to an existing well: lies or PNo 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infarnotion and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fornn.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction into
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).•You may also attach additional pages if necessani.
drilled: I / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a 00'and 2 a 100')
/ 24a. For All Wells: Original Ifonn to ;Division of Water Resources (DWR),
�Y
10.Static water level below top of casing: 3 (ft.) Infonnation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter: �/ (in.) Program,1636 MSC,Raleigh,NI 27699-11636
12.Well construction method: AIR ROTARY r
24c.For Water Supply and Open-LoopGeothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depiartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchI)g'over 100,000 GPID: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC'27699-1611
13a.Yield(gpm) Method of test: i
4 !
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY: i
E
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201
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