GW1-2021-01825_Well Construction - GW1_20210503

I L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: E f
1
14.;WATERsZ01%ES=,
Well Contractor Name KFROMJTOff DESCREP ON3�� SEC : aNC Well Contractor Certification Number MAY X3 2021 ,�.
5.OLtTER CASING fonmulh=cased'wells)'OR'Lg Ri if'a `lkhble
YADKIN WELL COMPANY,INC. n,aceSSIIl9 Uni FROM TO DIAMETER TID I':SS MATERIAL
Company Name
ft. ft.
011
3 _� DWIm R SeCn 16.INNER CASING OWTUBING eothecinal closed-loo '
2.Well Construction Permit#: 2� FROM To DIAMETER THICICNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ounty,State, Variance,etc.) ft. LaLf ft, e /Xs in. S 0 A vc-
3.Well Use(check well use): ft. fr. l in. ✓ Y
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE rvTHICKNESS MATERIAL
i_
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared)
I&GROUT'
❑Irri ation ❑Wells>100,000 GPD rROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: nFRONTO
ft. t^�O�r.�G ck e, ou—a
❑Monitoring ❑Recovery ft. /
Injection Well: � ge'1+/'t%f z
ft.
❑Aquifer Recharge ❑Groundwater Remediation❑Aquifer Storage and Recovery ❑Salini Barrier LPACK if.ii'licable"r:Ty MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer 20..DRIL•LING LOG afiach additional-sheets`ifhecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM T I DESCRIPTION color,hardness,soittrock type,grain size,etc.
ft. r ft.
4.Date Well(s)Completed:�L y�y� Well ID# � �yv fr. ,C ft•
Sa.Well Location: Phone #_33&1-3©2--S:rob 1`'l ft. ft. �� Q
.ltts cS'/11:t yU ft. q0 ft. to ru i�
FFaac�iliity/O er Name (Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
M 21.REMARKS
County ✓ , Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)3< 8 N r,` 22.Certification'
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6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
�// By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or A<o 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 information 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 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: (�.
t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3Q200'and 2©100D Submit this GW-1 within 30 days;of well completion per the following:
E
10.Static water level below top of casing: (fL) 24a. For All Wells: Original form'to Division of Water Resources (DWR),
If water level is above casing,use^+" ,1 If Processing Unit 1617 MSC,Raleigh,NC 27699-1617 �^
11.Borehole diameter: (in.) Bit Off: +w 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
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.) ` couniT environmental health department of the county where installed {
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1001000 GPD'Copy to DWR,CCPCUA I
t Permit Program,1611 MSC,Raleigh,NC 27699-1611 J
13a.Yield(gpm) Method of test: a a Y A)
13b.Disinfection type:
70%HTH Amount: Oz DATE SITE VISITED: 2—� t'!il i /Js�lvew
0 VISITED BY:
Form GW-1 — North Carolina Department of Environmental Quality-Division of Water Resources