GW1-2021-01492_Well Construction - GW1_20210415

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: [ r
1.Well Contractor Information:
4' In/ bro w A 14.WATER:ZONES
Well Contractor Name FROM TO DESCRIPTION k
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() A ` ft. f I 37o 4-7/
NC Well Contractor Certification Number A N rR 1 j 2021 a J 0 ft. , ft. r t f
15.OUTER CASING for•mdlfi-casiWwells)OR'LINER if a licable
YADKIN WELL COMPANY,INC. bl TO DIAMETER THICKNESS MATERIAL
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Company Name $ �A 7(?� �j 7 - .�3� I%!VR�.r.'Cvon
-L-Fr� e f/' 16.INNER CASING OR TUBING(aeotheir al closed-loo )
2.Well Construction Permit#: 2-0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) / ft. iffk. h jf/ in. 1 l
3.Well Use(check well use): t ( ft. I ft. in.
Water Supply Well: 17.SCREEN ('
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public g, in.
❑Geothermal(Heating/Cooling Supply) V'{esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. -3 ft. �n.��f<
❑Monitoring ❑Recovery ft. 0, ft. f' 1( /
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL T EIVIPLACEIYIENTINETHO
❑Aquifer Test ❑Stormwater Drainage ft. ft. 1
❑Experimental Technology ❑Subsidence Control t. ft.
❑Geothermal(Closed Loop) ❑Tracer 0.DRILLING LOG(attach additional sheets if necessaryv)
FROM TO DESCRIPTION(color,hardness,soiUrocle type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
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ft. ft. I sib i j S C
4.Date Well(s)Completed: 3-20 ' Well ID#A10`W/ ft. 1 6 ft.
Sa.Well Location: phone # 7 7:
I 11 ft. Q,10 n It.
Facility/Owner Name � Facility ID#(if applicable)
ft. ft.
Physical Address,City,and Zip IF ft. ft.
21.REMARKS
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) i
22.Certification: i
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6.Is(are)the well(s)• Wermanent or ❑Temporary Si attire of Certified Well Contractor Date
By signing this forma,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2<0 15A NCAC 02C.b100 or 15A NCAC 02C.0200 YVell Construction Standards and that a col�p
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 yvell 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: C 24.SUBMITTAL INSTRUCT16NS
9.Total well depth below land surface: I V (ft.) Submit this GW-1 within 30 days of well completion per the following
For multiple wells list all depths if derent(example-3 tt 00'and 2Q100') Y P P b•
10.Static water level below top of casing: [9 ® (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,:use t t
11.Borehole diameter: fl/ (in.) Bit Off: 6, 24b.For Injection Wells: Copyfto DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 2`7699-1636
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 produciny over 100,000 GPD: Copy to DWR,CCPCUA
� Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13a.Yield(gpm) 4. Method of test: r�
13b.Disinfection type: 70%HTH Amount: t P a OZ DATE SITE VISITED: c j �s
VISITED BY:
Fonn GW-1 1?^'u r arnlina Department of Environmental Quality-Division of Water Resources _ j _ Revised G-C-201 S r--r'