GW1-2021-06879_Well Construction - GW1_20210503

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—WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: �
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1.Well Contractor Information:
14.WATER,ZONES I
Well Contractor N a FROM TO DESCMTIOPI
5-7o-x--h
ft. ft. t
NC Well Contractor Certification Number 15.OUTER CASING'(for.m alti•cased wells)OR'LINE R if ap licable
YADKIN WELL COMPANY,INC. FROM I To DIAMETER I THICKNESS MATERIAL
ft, it in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 4 —Pc> FROM TO DIA MET- I THICKNESS MATERIAL (`
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ` ft. 791 ft. ,j I Z) n D fl,q')-'
3.Well Use(check well use): ft. fe. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) desidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT G
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEIYLENT rVIETHOD E AMOUNT
Non-Water Supply Well: �1tj ft,
❑Monitoring ❑Recovery ft. y­,ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL EIVIPLACENIENT MICTHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer - 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCUPTION(color,hardness,soiltroch type,grain size,em.)
❑Geothermal(Heating/CoolingRe/tun) ❑Other(explainunder#21Rte'markst)1 ® ft. G yft. �orl.
4.Date Well(s)Completed: �+ I Well IID#A Ao— F-_� T �A�I ft• 7 S` it• Qr,� n p/ o
Sa.Well Location: Phone # 7d� - D r 7 St. 3F ft' /71.,*/ ../ �•� � �� C raLyr.'¢
�.� �� ��� 3�ft. 3 S/a•ft. '�A�� �t`a f tea,.;�.e
Facility/Owner Name // Facility ID#(if applicable) ft. ft.
6 eU t Is'"� f \ ft. ft.
y
Physical Address,City,and Zip
ft.
21.RENIARICS AA n
County Parcel Identification No.(PIN) wIH
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "
processing t)Illt
(ifwell field,one lat/long is sufficient) 22.Certification:I t'V 6�_llR S e c i i 0 n
o Z. N 'S� ��. c� � � W
6.Is(are)the well(s): dermanent or ❑Temporary Si re of CertifM Well Contractor Date
By signing this form,1 hereby cei*6i that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t*/N o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Krell Construction Standards and that a colw
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 ofthis form. '
23.Site diagram or additional well details:
8.For Geoprobe/IDPT 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 isneeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessari.
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drilled: ) 24.SUBMITTAL I NSTRUCIl'IONS
9.Total well depth below land surface: `S� r (ft.) Submit this CW-1 within 30 days of well completion per the following:
For multiple wells list all depths if eli ferent(example-3 a 00'and 2 c@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,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: /® 24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 6
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depaI tment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over,100,000 GPID: Copy to DWR,CCPCUA
^�0 t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) a �� (Method of test:Air � ;6f7 4
70%HTH S`- OZ DATE SITE VISITED: J-d 1-4 1
13b.(Disinfection type. Amount: ��-
VISITED BY:
Fomr GW-1 - + North Carolina Department of Environmental Quality-Division of Water Resources i�:2 Revised 6-6-201 S'1.(