GW1-2021-06272_Well Construction - GW1_20210915

VVEEiL CONSTRUCTION RECORD �GVV-D For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION i
9OJ� ft ft
30 3 C ft. ft. Q
NC Well Contractor Certification Number
IS.OUTER CASINO formulti cased Wiens OI3I11 ER ofa licafole
YADKIN WELL COMPANY,INC. FROM To DIAMETER =CKNEgg gqATP.RTA r1
Company Name %
�� 16,lI1IlVER CASING OR TU]3fi4G eothermal closed-lao
2.Well Construction Permit#: FROM TO DIAPtIETER rgg �7ErS3 BIATERIAL
List all applicable well construction permits(i.e.07C,County,State, Variance,etc.) ft. -7 ft 6'l� in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIB a9ATE1QtAL
❑Agricultural ❑MunicipaI/Public ft. �—
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) I0 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METBOD&AMOUNT
Non-Water Supply Well: ® ft fr.
❑Monitoring ❑Recovery
Injection Well: ft
ft fr.
❑Aquifer Recharge ❑Groundwater Remediation
uifer Storage and Recovery 19.SAND/GRAWE'L PACK ifa licable
❑A
q ery ❑Salinity Barrier FROM TO MATERIAL Ett�'LACEMLNTNaE$1�OD
❑Aquifer Test ❑Stormwater Drainage ft. r�
❑Experimental Technology ❑Subsidence Control ft Ci
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING I OG attach additional sheefs if nem isa ®a
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DFSCRrPTTON(color.hardness,sa8vraek ftp. ,to sae,ere
4.Date Well(s)Completed: m Well Wft AAV, ft ft
5a.Well Location: Phone # , ���2qm �,� �� &
ft ft
Facility/Owner Name Facility ID#(if applicable) ft• ft
----------------
d� �• 8 ® _
tffP e n: �'at
Physical Address, 'ty,and Zip gg ft. ft. _
A lb4AaAC� 110 ® U � 21.RE
County Parcel Identification No.(PIN) U' I➢
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I DVVR Section
(ifwellfield,one lat/longis sufficient) 22.Certification•'
360 N 7m 0/78 W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor i Date
By signing thisform,l hereby cent*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an e7dsting well: ❑Yes or to 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 remarkr 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 Remadcs Box).You may also attach additional pages if necessary.
drilled:
�q 24.SUBMITTAL INSTRUCTdORIS
9.Total well depth below land surface: @2 -/1'd2 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferenl(example-3@200and 2®100) umy
10.Static water level below top of casing: 1'D/1 0 (ft) 24a. Por .ill ie
Wells: Original fo '.to Division of Water Resources (M),
Ifwaier level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
(• ) Bit Off: 24b.For Injection Wells:Co WR,Underground Injection Control(IUC)
11.)Borehole diameter: (in.) Copy to D
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY(i.e.auger,rotary,cable,direct push,etc.) 24c.1+or Water supply and® n-> o
per oD Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water We producine over 100'000 G)PID Co to D
' Permit Pro 1611 MSC,Ralei h NC 27699-I6I I Copy CCPCUA
13a.Yield(gpm) Method of test: ��� �n/' �� gt 1
13b.Disinfection type: 70%HTH Amount: 626 OZ DATE SITE VISITED:
Pri ef--'.Aj4 t d lry VISITED BY: ppgg G
Form GW-1 a _. n _ 1Jnrth('arntina nPna�.,,a,....a c.........---,_,...._, ,-,--'------<..,.. .• _ R e,. s h N' V