GW1-2021-07083_Well Construction - GW1_20210915

IIJ,fL CONSTRUCTION RECORD CORD MV-1a For Internal Use Only:
'.Well Con ractor Information: R -�
Me w Sett w ki 14.WATER ZONES I
Well Contractor Name FROM TO I DESCRIPTION
3®3
NC Well Contractor Certification Number
15.OUTER CASING for multi-rased wells)OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER ss MATERiAI rim
fr. ft
Company Name 4'.1 ylf r A., TF - �C(o c 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:jd J M `C71:• 3 Q FROM To DIAMETER I THICICMS I NIATERIAL
List all applicable well construction pe mits(i e.UIC,County,State,Variance,eta) 107 ft. 1/` in. d-a p c
3.Well Use(check well use): ff. fr. in. 'i!/h V
Water Supply Well: 17.SCREEN
❑Agricultural
FROM TO DIAMETER_ SLOT SIZE TMCIOYESS MATERIAL
❑ unicipaUPublic ft. ff. in.
❑Geothermal(Heating/Cooling Supply) 2esidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IrrI atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
❑Monitoring ❑Recovery 3 tt 2 3ft. D wt7�o st PV
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMINTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft•
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling RetLun) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soivroek typa grain size,etc
/�
ft ito ft ,
4.Date WeU(s)Completed:9- 2�-Well ID# h-P- L go ft / ft. oCkg G
5a.Well Location:
//�� Phone #,TXv 2 S P- 0� t0�- ft' G r a n�r
:37an-CJ V�/�¢�/' �/ ft ft.
Facility/Owner Name Facility ID#(if applicable) ft• fr.
'7o 6 q Wr- 4* C? F y f�'e,;,.-J
Physical Address,City.and Zip ft ft
21.REMARKS
1 1/ ,Q.,�
County Parcel Identification No.(PIN) t -S^"„) i01 i�i!rC,S Rij sa9ll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR SeC11011
(ifwell field,one lat/loagis sufficient) 22.Certification:
IS 0-1
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
If this is a repair,fdl 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 G�-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: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'•and 2©100)
6 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwa[er level is above casing use f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) Bit off: �� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,I636 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 over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 276 9-1611
13a.Yield(gpm) Method oftest: P)g a,r „�(�� Z,r-Z1
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: ��! �'�i � su Jev
t1v`
VISITED BY: I