GW1-2021-06800_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.',WXTER-'Z0NES_.
Well Contractor Nte FROM- TO F DESCRIPTION.
31616 ft3 ot ,,Re-4c,rAl /.x)
NC Well Contractor Certification Number 0
YADKIN WELL COMPANY,INC. FROM 70 DIAMETER THICKINESS MATERIAL
in.
Company Name
16.-INNER CASING'ORTUBING10i6th r 1,616idil(W),
2.Well Construction Permit#: S Al F 3 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits rt.e.LaC,County,State, Variance,etc.) 41ft. 27 !J&42�� in. 11D9_Q'-1 FIA-
3.Well Use(check well use): ft. . ft. I i in. I
Water Supply Well: 17.SCREEN:, C
FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
oAgricultural ElMunicipal/Public ft. ft. in.
oGeothermal(Heating/Cooling Supply) desidential Water Supply(single) ft. ft. in.
0Industrial/Commercial OResidential Water Supply(shared) -4ittkOUT
DIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -e fop
-
oMonitoring DRecovery JL*rAJ
Injection Well.- V
DAquifer Recharge OGroundwater Remediation
;19"SAND/GRAV.EL--PAC-K'(if-'i'� licibli)' •OAquifer Storage and Recovery ❑0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer '10DRFL-WNG-10G`(nfff_chaddifioiiiil
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM To DESCREON color,hardness,soillrock type,grain size,etc.)
4.Date Well(s)Completed: well EmMO- 329 ft. ft. 1 M0,*Z-ol es--
ft. ft. 2A
5a.Well Location: Phone # $et/. 7X_g� q67
3bTft. el -5-'e AJ A2 LS tf (Atzm
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3�6eJ2-1 V X ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS .,f"q Ap'—
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lattlong is sufficient) 22.Certification:
Qk 0 3 S" N 9-6" V-9', Q Y-I W
ow
n tr
6.Is(are)the well(s): 6ermanent or OTemporary
Sigg Pning I
ring this form,f Certifi ell Con actor Date
1 hereby certify'lhat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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 921 remarks section or,on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or:dlosiid-Loop Geothermal Wells having the same
, ' w (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW 1 Is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. Submit this GW-1 within JU days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
3S' 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"+"I
11.Borehole diameter: I—(in.) Bit Off: 5.177 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUQ
Program,1636 MSC,Raleigh,NC
C 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 TILLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
I Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)I(J 0 Method of test: too�&�
13b.Disinfection type: 70%HTH Amount: (0 Oz DATE SITE VISITED:
VISITED BY: Vz
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018