GW1-2021-01862_Well Construction - GW1_20210503

Q. ",1J CONSTRUCTION RECORD, (GW-11 For Internal Use Only:
1.V;'ell Contractor Information:
U_
M WATER ZONES
Well Contractor Name iFROM TO DESCRIPTION
3036 ! 7 ft. it ft. (fin
G It. .1 y
NC Well Contractor Certification Number '
is. fo"rm OUTER'CASWG ulti-casid rvells'YORLINEIC(ifi" licible"
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
f ft.
Company Name
4p -3O o 16.INNER CASING OR TUBING '"eotbermaCclosed46o
2.Well Construction Perm, L FROM TO DIAMETER THICKNESS MATERIAL
Lisl all applicable well constriction permits(i.e.UIC,County,State, Variance,etc.) 41 ft. ft 6 f/ 1O SP' -21 01/
3.Well Use(check well use): ft. ft. in. /�
Water Supply Well: 17.SCREEN i.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) fResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S:=GROUT _; s�
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft
❑Monitoring ❑Recovery ft. e,IL
Injection Well:
fL fL
❑Aquifer Recharge ❑Groundwater Remediation _ —
19:'SAND/GRAVEL PACK(if i"livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD `
❑Aquifer Test ❑Stormwater Drainage ft
I
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer `20.DRILLING LOG attacb'additional sbeets if uecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rook e gmin size,etc
ft. 9® ft.
ft.f n
4.Date Well(s)Completed: �7"Z Well ID# D 2 G © t. 6,�
Sa.Well Location: Phone # ft. ft.
Facilr�-nKe p-7 ft. ft
ty am / Facility ID#(Applicable) IN 'I
6 J PL/1/!✓f 1
Physical Address,City,and Zip PQ' y, s ft. ftAN i O't
r,r G(�r4W I 21.REMARKS
County Parcel Identification No.(PIN) ^ ;•:lo
I1�(DrF✓S51 1fJ tl m
UvNR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
'D
(if well field,one lat/long is sufficient) 22.Certificati
o N l 0 3, w Jr
6.Is(are)the well(s): Aermanent or ❑Temporary Signattue of Certified Well Contractor Da e
By signing this form,l hereby certij�that the well(s)was(were)constructed in accordance with-
7.Is this a repair to an existing well: Dyes or f 10 15A NCAC 02C.0100 or 1.iA NCAC 02C i 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: a 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 dierent(example-3@200'aand 2 0000�
6 Q ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use
f Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+" , •
11.Borehole diameter: (in.) Bit Off' 70 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUQ Q.
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.) county environmental health department of the,county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oven 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 7 Method of test:
Permit Program,1611 MSC,Raleigh,iNC 27699-1611
�r� S'
o �' '� DATE SITE VISITED: 3 ^ l
13b.Disinfection type: 70/o HTH Amount: OZ ,
VISITED BY:
Form GW-1 —orth Carolina Department of Environmental Quality_Division f Watez Resources 1 I Revised 6 2018