GW1-2021-05558_Well Construction - GW1_20211013

ICONS TRUCCTI'ON RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
SLAn S e 14.WATER PANES i
Well Contractor N e FROM TO DESCRIPTION
c' 8 rt. 3`a ft' 14 �m P•Pf _�
�'lS3 1.0 vt��ti ft. G y0 ft. 3 Po
NC Well Contractor Certification Number �C ����� 15.OUTER CASING for mul&cased wells)OR LINER if a licable
r fS� r�
YADKIN WELL COMPANY,INC. �1G .•�O� FROM To DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name �O=1 p�+
��' 16.INNER CASING OR TUBING 'eothermal closed-loop)
FROM TO DIAMETER THICKNESS
2.Well Construction Permit#: MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) L q G it 1II' S DR;I P VC
3.Well Use'(checkwell use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) bResidential Water Supply(single) ft. ft. in. r
❑Industrial/Commercial residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft' fi' I4ok Hui Pv.lftA #4
❑Monitoring ❑Recovery 3 ft. 33 fi' OwwA &;A F 6 r,r-c-1 4.1104
Injection Well: ft ff.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACENMNTMETHOD
❑Aquifer Test OStormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
1iGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
bGeothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION corer,hardness aoil/mcic Ins¢ etc
t
A.pate Well(s)Completed: 8 31 I3l Well ID# ° 31? R •'�3Z h a�[
sa Well Location:
Phone #114V3�-ASS-e3JP6 � ft
0 °�1 ft. ft.e 5 Fact7ity/Owner Name Fac ' �(if applicable) ft. ft.
,t ft.
Physical Address,City,and Zip ft ft
/ 1� 21.REMARKS
(i(� 'l" •-Lf-i-4-4/-
County d/ Parcel Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwel]field,one lat/long is sufficient) 22.Certification.
N a"! 3 0. /_6'� W 4." Lam, g 3 r a i
6.Is(are)the well(s): ermanent or ❑Temporary Sign a of ertified Well Contractor Date
By signing thisform,I hereby certify1hat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
te
If this is a repair,,frll our 66wn well construction hTformation and explain the nature of the of ibis record has been provided to the well owner
repair under#21remarksseectron or anfhe back ofthisfarm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
construction,only 1 GW--i is i eded: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: 7 2 2 (ft) Submit this GW-1 within 30 days of well completion per the following: a
For multiple wills list oll depth's/fWlfferent(example-3(a)200'and 2©100) (A
S" (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
40-Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater;level is above casing,use"+"
11.Borehole'diameter (in.) Bit Off: G•012 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636 T
12..Well construction method: AIR ROTARY 24c.For Water Supply and OpeA-Loop Geothermal Return Wells:Copy to the
(La.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 + j
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: e`w /
13b.Disinfection type: 70%HTH Amount: 33 OZ DATE SITE VISITED:
VISITED-BY: �� r, i`S