GW1-2021-01850_Well Construction - GW1_20210503

C L CONSTRUCTION RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
10 t S 14.WATER ZONES I
Well Contractor N e FROM TO DESCR❑'T►ON
9) rt. �y
S 7�-� )-7ft. �� ft. a fv�e /-�`k
NC Well Contractor Certification Number 15.OUTER CASING(for`nnul&ased'AAIs)OR L[NER'if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TBlclavEss MATERIAL
ft. ft. , in.
Company Name �a�a a 3 'G`7 W� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: -7 6 cyo FROM TO DIAMETER THICICNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) / ft. [� ft. ,,,ZS'rn• S 1'�' ( (��
3.Well Use(check well use): ft. ! fr. in.
Water Supply Well: 17.SCREEN
FRONT TO DIAMETER SLOT SIZE I THICICNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) 1111 esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) tS.GROUT
❑Irrigation ❑Wells>100,000 GPD FRONT TO MATERIAL EIVIPLACEIYIENT METHOD&AR90aJRIT
Non-Water Supply Well: ® ft. L/ fr. /3{.,I-C- e r
Ot9U
❑Monitoring ❑Recovery tJ eft. ft.
Injection Well: 7 30 1�eA .8/J 0
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(i£a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM[PLACEI4rENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attacla'additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soit/rock e, rain size,etc)
❑Geothermal(I Ieating/Cooling Return) []Other(explain under#21 Remarks) d ft. y aft. i
4.Date Well(s)Completed: �'� Well EM: J G ft' G eft. `'t� e./
Sa.Well Location:
Phone # 4', i "�� ft. ft.
p� it. ft.
Facility/Owner Name ��/f Facility ID#(if applicable) ft. ft.
12C �t'iLsTl.�( �/ /"�'4.ff✓I �� ft. ft. pN '*r
Physical Address,City,and Zip
GOvI 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -;,rwatinn Processing U1111
(if well field,one lat/long is sufficient) 22.Certification: DWR Seciion
�Jt)N 6 •2 cl. 8'0 S W
6.Is(are)the well(s) dI'ermanent or ❑Temporary Si e of Certi£ el6r Date
By signing this form,I hereby cer{ify that the we/l(s)was(were)constnacied in accordance a iih
7.Is this a repair to an existing well: ❑Yes or L No 15A NCAC 02C.0100 or 15A NGAC 02C.0200 Well Construction Standards and that a calm
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 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
i construction,only 1 GW 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: ! fir- (ft.) Submit this CW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 t@t 200'andt2 JQ100')
10:Static water level below top of casing: `�®, (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wirer level above casing,use
Bit Off: 5,a 24b.For Injection Wells: Copy to DWR,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 andiOpen-Loop Geothermal Return Wells:Copy to the
(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
13a.Yield(gpm) Method of test: alp
/g� Permit Program,1611 MSC,Raleigh,NC 27699-1611
•� 6
13b.Disinfection type: 70%HTH Amount: -j�^ OZ DATE SITE VISITED:
VISITED BY: ri vJU
Fonn GW-1 w� _ _North Carolina Department of Environmental Quality-Divi iqi of War Resources �._1 `/�, Revised 6-6�)