GW1-2021-01837_Well Construction - GW1_20210503

For Internal
CONSTRUCTION RECORD (GW-1) Use Only:
1.Well Contractor Information:
plot 14.AWATER,'ZONES__'
Well Contractor f. FROM TO DESCRIPTION
NC Well Contractor Certification Number 15.OUTER CASING(for in_u1Wcise& -(& ble�0�1%Tr RL R
TO �TE2=
YADKIN WELL COMPANY,INC. FROM I DIAMETER 11 TE11CIC4ESS
RIAL
ft. in.
Company Name CaA C-ue_'v cfz R5­1 ck 16.INNER CASING OR TUBING i iLcIdied-ldop)
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.TffC,County,State, Variance,etc.) ft. in. S -yl PV4.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O.Agricultural []Municipal/Public in.
oGeothermal(Heating/Cooling Supply) Iide,id.ntial Water Supply(single) ft. ft. in.
ElIndustrial/Commercial DResidential Water Supply(shared) -18.GROUT
oIrrigation oWells>100,000 GPD FROM TO MATERIAL ENIPLACEME,NT METHOD&AMOUNT (b
p.,
Non-Water Supply Well: . r .0--( 's
oMonftoring ORecovery -L 04
Injection Well:
oAquifer Recharge DGroundwater Rernediation
19.SAND/GRAVE L PACK'(ifh0pIicabIe)-.'
OAquifer Storage and Recovery oSalinity Barrier FROM E,ft. TO MATERIAL EMPLACEMENT METHOD
13Aquifer Test OStorrawater Drainage
ClExperimental Technology oSubsidence Control
DGeothermal(Closed Loop) oTracer
DESCRIP
[]Geothermal 04eating/Cooling Return)) 0 Other(explain under#21 Remarks) FROM TO TION(color,hardness,soiVrock type,grain size,de.) O
v ft- �J Sr
Well ID#
CS)
4.Date Well(s)Completed: AQ87 Q rft- 3�-P•ft- m e,,,'1
Sa.Well Location: Phone
e�C-4?b rA I a R r 0 P1
Facility/Owner Name C t?Facility IDA(if applicable)
ft. ft.
kt!25.r ve-lk C k -d Leno i'y
Physical Address,City,and Zip
21.REMARKS
Id 0( W
County Parcel Identification No.(PIN) proce Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
-of
j 9j2n N . 01
6.ls(are)the well(s): aermanent or ElTemporary Sign gWeof Ckfified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or St/41 15ANC,4CO2C.0100orl5ANC,4CO2C.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 921 remarks section or on the back of this form. 23.Site diagram or additionalwell 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 GWJ is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box) You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
**
9.Total well depth below land surface: 3;a -(ft') Submit this GW-1 within 30 d lays of well completion per the following:
For multiple wells list all depths irdifferent(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,16�1 7 1,MSC,Raleigh,NC 27699-1617
If water level is above casing use"I
Bit Off: 24b.For Injection Wells:Copyto DW R,Underground Injection Control(IUC)
11.Borehole diameter; (in.) Program, 1636 MSC,Raleigh,NC 27699-.1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Osier-Loop Geothermal Return Wells:Copy to the
(i.e.wager,rotary,cable,direct push,etc.) county-environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing,over 100,000 D: Copy to DWR,CCPCUA
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) A10 Method of test: I I I
13b.Disinfection type. 70%HTH Amount; OZ DATE SITE VISITED: '�' 11/ 2-_� 2-
VISITED BY: -.D In?�
77-t:w_l North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018