GW1-2021-06281_Well Construction - GW1_20210915

x f
—m -,ci�TL�a�1�`T5ll 'l[T�1TT1 ON RE CORD(GW i1� For:'Iriternal Use Only 1.Well Contractor Information: -
r
RZ� 14.WATER aft 3i
FROM, TO DESCRIPTION la l
Well Contractor Name
NC Well Contractor Certification Number 95 s
�Q 15.OUTERCASING foraiulh-cased,wells .ORjLINER'if;a ticatili
(� �_0 FROM 'TO DIAMETER F�i*,TMC10MS A1KATERLIL
YADKIN WELL COMPANY,INC. � F�O� m
Company Name (r 2P�,� x`
�t ` d 16.INNER CASING OR TUBING 'eotirermal closed lco
2.Well Construction Permit#: FS� FROM TO F DLAME=E 40 1TMCKMS7iIlIS IMATERiAI>
List all applicable well construction permits(ce UIC County,State,Variance eta) `a, , -t' ft 8 it k.ZpPi/y .' S�K
ty
' r'�'R 3 ••."'M1" �;ft
3.Well Use(check well use): r s k
Water Supply Well �•* x17.SCREEN
PP cCi '> M IO 't."" .DIAMETER a SLOT:SIZE' TRICIOVESS�fMi►TERIkL�
❑Agricultura] ❑Muntcipa]/Pbltc it:j ft m
❑Geothermal(Heating/Cooling Supply) li l)esidential Water Supply(se ngle) ft: "`ft�'` - ro
z`
[:)Industrial/Commercial ❑Residential Water Supply(s -GROUTm
'" ? ' FROM -.' TO3+ i SMATERIi1L�l #EMPLACE+T'tENT,IMETHODT&!'AMOUNTA
❑Irrigation ❑Wells>100,000•GPI)
Non-Water Supply Well: Lrl7 tt �5 aa�;WOAW I pommN 1
❑Monitoring ❑Recovery r sit ®iv�k
5 o ��.. PLC_
Injection well: w
il
❑Aquifer Recharge ❑Groundwater Remediation
19..SAND/GRAVEL�RAGIO if a liciitile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM'::. ';TO' !MATERIAL #UOLKCEMENrME17ioD�
❑Aquifer Test OStormwater Drainage
EBxperimental Technology . ❑Subsidence Control. it
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING'LOG'a"ttachla'dilitioii3lsheeisif,neeeasa.
�c FROM�#�`,x LTO' lDESCRIPTION`eotar?hudn'en-•1idiUmek ""ri's'
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) Y �
4.Date Well(s)Completed: t6 Well ID#A f l7d�Uft' (j 11
5a.Well Location: Phone # :)S,- 864
Fatuity/Owner Name lY Facility ID#(if applicable) 1 ft
4�1:(0 l.avrel R�cir•P. fir. Le�olr
Physical Address,City;and Zip 0
r.�21 eREIVIARKS
CAki weld
County Parcel Identification No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees. agr� r
(ifwell field,onb lat/loagis sufficient) 22 Cerlif�eatlon:,
r
6.Ls(are)the well(s): li�rmanent or ❑Temporary S o�tfied Well Contactor Date y
�/ By signing thfsform,l herebycerhfy at the+well(s)was,(were)conshucted:in accordance ifh
7.Is this a repair to an e:risting well ❑Yes or [1gPIo 15ANCAC 02C 0100� oar 15ATMCAG.02G.0200�elJ, -ons c 1on SYanddFW-d-Ur ,a copy
r o�`A F6 d has been rovJded to fh J;owner.
If this is a repair,fill out known well construction information and explain the nature of the p
repair under#21 remarks section or on the back of this form.
3 '23 Site diagram or additional well;details:
Ynil i li the'back of this page tolprovide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same .� �a..a, •af
add'See Over',m Remarks Box.You m also;attach additional, cif necess
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ) aY P
drilled: G `i1�1 SIJBMTITAI,TNSTRU:CTIUNS
9.Total well depth below land surface: y Y (ft)' zhiQh a, ' s
For multiple wells list all depths/fdiffereaf(ezarnple-3(a)200`dird 2Q10171 Submttthts GW 1 within 30 days of well completion per the following:
�24a , ll�wells Original.form to Division of Water Resources (DWR),
10.Static water level below top of casing: �'®D (ft.) <hifomtahon Fo r,AProcessing Unit17 N SC,Raleigh,NG 27699-1617
Attwafer level is above casing,use"+" `ri r .s t •. +
Sit Off: G.QO'� Z4b For Intection Wellsr`Copy tDWR,Underground Injection Control(IUC>)
11.Borehole diameter: �O (in)
Program,1636 MSC;R"aletgh,fNC 27699-1636
AIR ROTARY F.
12.Well construction method: pu r l'
24c Water,Supply,and.Open'LooD:Geothermal Return W.,,ells:Copy o the
(i.e.auger,rotary,cable,direct push,etc.) county envuonmetital healtt►departntgnt.of the:co—itnty whiiistalled
FOR WATER SUPPLY WELLS ONLY: Z4d For WatecyWells Droducan err100,000 GPD:Copy to DWR,CCPCUA
PermitPiogram,�1611MSC�RaletghNC:27699'161�1 �J,�
13a.Yield(gpm) 1��+ Method of test: ®� - •� � > ' oZ
DATE SITE VISITED , �yW �:w''
13b.Disinfection type: 70%HTH Amount: Oz
VISITED BY
P r i r-P F ¢
____• ter- .,_�'_— __�"'`-_.-CC----�......I..1 ll..;.l.f:.:':T...........:L�si..s��o^`'`-........$;i3�� - n..-�...IC L'1nl:Q