GW1-2021-06824_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
�.
() 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
i�CCs;��SlCttJ.
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)
''//// ow Y
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
l\ i
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
f'
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
`3 I/
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'

JLIL CONSTRUCTION RECORD (OW-1) For Internal Use Only: C
1.Well Contractor Information:
_ ✓ \ �(/ L► Owe 14.WATER ZONES t I
Well Contractor Name � FROItI T4 DESCRIPR ION
IV' ,9r1ft. ���� it. C�
E f/V ft. ft. � r
NC Well Contractor Certification Number f1 15.OUTER CASING for multi-cased wells)ORLINE-x if a `licuble
YADKIN WELL.COMPANY,INC. APR `� 2Q2� FROM TO DIAMETER THICKNESS K&TERIAL Gr
ft. ft. in.
Company Name fGCL'fi J'
e'q 0 1nfoim3t y_Ction 16.INNER CASING OR RING geothe'rroal closed-too )
2.Well Construction Permit#: '� Z� � PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc..) ,#. ft. ft. f in. ,�2 t Q / (�
SD
3.Well Use(check well use): ft. 6 ft. •�+ in. 7 v v
Water Supply Well: 11.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural O1Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) dkKesidential Water Supply(single) ft. ft. in•
OIndustrial/Commercial OResidential Water Supply(shared) iti.GROUT
OIrri ation ❑Wells>100,000 GPD rROM TO MATERIAL EMPLACEMENT METHOD Fe AMOUPIT
Non-Water Supply Well: O rt. L# ft.
OMonitoring DRecovery ft. ft. t
Injection Well: T
ft. £t.
OAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PAC hti.(if a liciible),
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage
DExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20."DRILLING LOG attach additi4nal`sheets if necessary
$ '' FROM TO DESCRIPTION color,bordness,soil/rocic e,arvn si c,etc.)
OGeothennal(I-)'eating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft f G1"
k 44:Date Well(s)Completed: 2�=;^9t Well ID# /Ke.1 iA/01 A4G
. `. 5a.Well Location: Phone # 3SZ 'Y<C! g J ft. ft.
Facility/Owner Nkine FacilliityyIID#(if applicable) ft. ft.
'Ile ft. ft.
Physical Address,City,and Zip ft. ft.
2I.REMARKS
County V� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwclI field,one lattlong is sufficient) 22.Certification:
6.Is(are)the weil(s): !&7Krmanent or OTemporary Signature of Certified Well Contractor ! Date
// By signing this form,I hereby certijJ,that the well(s)was(were)constructed to accordance with
7.Is this a repair to an existing well: DYes or iVo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Krell Construction Standards and that a colrl,
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 Nell owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details: I
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 I OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necossar.
drilled: J ' 1 l 24.SUBMITTAL IINSTRUCTIONS
9.Total well depth below land surface: &•� (ft.) Submit this CW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierem(example-3 c@200'and 2 t@100')
v 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"+" ,r a
11.Borehole diameter: (in.) Bit Off: 66�,' 1 Ll 14 24b.For Injection Wells: Copy toGDWR,Underground Injection Control (TUC)
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 zile
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where in IIed
FOR WATER SUPPLY WELLS ONLY: 24d.1For Water Wells producing o,vei•100,600 GPIID: Copy to DWR,CCPCUA
®� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: j
13b.(Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:2-k
- VISITED BY: i
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