GW1-2021-01868_Well Construction - GW1_20210503

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7-COIIIS ITRU CZIOIN�(CORI (GVY-111 For Internal Use Only: i
:i.Well Contractor infor7adon:
[ "!4t Try PiK/ �(1)L J i1 14._bYATER ZONES I
Well Contractor Name FROM TO DESCRIPTION T
30 C!/7 8 3 ft. ll o ft
ft. ft. C
NC Well Contractor Certification Number
15:OUTER CASING fo"r-multi-cased NJells)`OR L1NER"if a �livable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICIQVESS IYfATERIAL
Company Name l
` 16.INNER CASING OR TUBING 'eothermaLdosed-lob )
2.Well Construction Permit#: S�✓vC r✓ "O T S 3 FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• ft. in. QQ'�
3.Well Use(check well use): r-SO ft' ft' rn. .<t S�� N �
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, t. in•
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ❑Wells>100,000 GPD �-
Non-Water Supply Well: tr. 3 ft. G I Q
(-
❑Monitoring ❑Recovery 3 ft. 2 L ft. S Vr t7v !<L
injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applitablo
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENIPLACENIENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.
0 ft. S�U ft
Ll-Gb � Well - 3U ft' ft'4.DateWell(s)Completed:
; d- :6/
5a.Well Location: e / Phone # .5d 8-5G7-7'(j ®ft. �7 ft. �[ V CI
P �G,.hGr� L. . ? ft. .2 90 ft. It" L,
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip ft. ft.
t; ^Pw� 21.REMARKS
County /,J Parcel Identification No.(PIN) 411
N 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �I_
n P.r;�SSiIIF�Lill
(if well field,one lattlong is sufficient) 22.Certification: li I'Ojl ,ap v"`��.c?ECi1Q1►
35 'fY, 4Y1/o N 8'z DVS 5�'7S 9 W
6.Is(are)the well(s): C ermanent or ❑Temporary ignature of Certified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Po 15A NCAC 02C.0100 or I SA NCAC 02C.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 thisform.
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v (ft.) Submit this GW-1 within 30 daysfof well completion per the following:
For multiple wells list all depths if different(example-3 t©200'and 2(a)100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
`
10.Static water level below top of casing: / 3 o (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: -�. Q 7 D`r 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) O 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100000 GPD:_Copy to DWR,CCPCUA
( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �� Method of test: 4t tY Gk A�03
o O DATE SITE VISITED: Q -
13b.Disinfection type: 70/o HTH Amount: C OZ
/-1 �'t'N VISITED BY: �o �t a•� '�`
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018