GW1-2021-05326_Well Construction - GW1_20211013

VVEL ON J�TU�T��G►1�LU'Lflr iw-211 For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES ! _
FROM TO DESCRIPTION
Well Contractor Name 30 G& M
NC Well Contractor Certification Number n�T 3 20�1 15.OUTER CASING for mnlfi cased wells OR LINER(if applicable)
YADKIN WELL COMPANY,INC. 11 1 Q�y� FROM To DIAMETER TffiCKKESS MATERIAL
_ ft. ft. in.
-„Company Name , {Oi1,^3t jR�J,oC1!On 16.INNER CASING OR TUBING eathermal closed-loo
I .•Well Construction Permit.#: �3° FROM TO DIAMETER THICIQVESS MATERLIL
2
Lis(al applicable well construcilan permits Ae.UIC,County,State,Variance,etc.) 1�l IL ft. G/ in. OR a It
ft. ft in.
3.Well Use(checkwell use 1- °\
17.SCREEN
Water Supply Well-',-' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
r •a 17Agricultural ll.` OMunicipal/Public ft. ft. in. (�
.�OGeotherLnal(Heatuig/Cooling Supply) residential Water Supply(single) ft. ft. in.
•; ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT �.
❑IL•figation ` ❑Wells>100,000 GPD FROM TO MATERIAL .EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' ` Mak PI �l 104 j_
❑Monitoring ORecovery 44 ft Pq ft Qui e k e r0 PN 164 CS
t
Injectiou Well:, ft R
'OAquiferReeharge ❑Gcoundwat, Remediation lrA 19•SAND/GRAVEL'PACK(if a licable
51jAquifer Storage and Recovery ; ❑Salinity Banter;t r ` FROM., To MATERIAL ENLACEMENT METHOD
❑Aquifer Test 0&6imwater Drainage ft f4.
bExperimental Technology ❑Subsidence Control A a fk ft.
' ❑Geothermal(Closed Loop) 'OTracer 20•DRII,LING LOG attach additional-sheets if necessary)
<, - FROM To � d DESCRIPTION color,hardness,soilfrock G nia size,etc
❑Geothermal(Heating/Cooling Reti m) []Other(explain undei#21 Remarks). � 5,., �• n
4.Date We11(s)Completed: Well ID# 6 s� R' 142 ft' ,A 64
ft ft
5a.Well Location: ���— — `
�-I Phone # y
it—AcA e1��G�GV t�B Q. �NG C C ft. ft
Fsa7ity/Owner t, Facility]D#(if applicable k4 Ol ft' ft j l
_� l..e-?� � 7 �n/` tit ��G4eC0 L✓S�i� - ft ft.
T .
� a �,j C ft. ft )"
Physical Address,'City.and Zip 6 O�•l N l F �9�®�'C•
1, a 21.REII4ARKS
County Parcel Identification No.(PIN) {
L t
5b.Latitude and longitude in degrees/minutes/secondslordecimal degrees: t.
Q° (if well field,one lat/long is sufficient) i 22.iCerdication: ~`
¢ . 3 �e z!. q Z9`r N al V, �o0 - - . 2c
f'� i•., F`_Signature "Ce d Well Contractor Date
6.Is(are)the well(s):.Wermauexit or ❑Temporary ,
h, By signing thisfortn,I hereby certify that the well(s)was(were)construcied in accordance with
7 Is this a repair to an existing well ❑Xes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Staridordr and that a copy
yy���'
If this is a repair,fd!out known well construction information d explain the nature of the of this record has been provided to the well owner. '
' form. '
repair under#11 Hinarks section oron the back of this
23 Site diagramWr-additional well details:
8.For Goo robe/DPT or Closed-Lao Geothermal Wells having the same You may use the hack of this page to provide additional well construction info
( p p add'See Over'in Remarks Box),You m also attach additional; >f necessary. �J
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER Of wells ,� ) �' p ,ty arY'
drilled: i �' 14 SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface:. Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths f diffenenl(exanip/e 3Q200-and 2@100) )
3v 24a. For All Wells: Original form to Division of Water Resources(DWR); _
10.5tatic vrater9ev11 below top of casing: (R),=Infomntion Processing Unit,1611 MSC,Raleigh;NC 27699.1617
If water level is above wsot&use-
r„+ r
Bit Off a�'d D + �Z4b•For Infection Wells Copyto.DWR,Undergrond Injection Control(1'UC)
11.Borehole diameter: :� (�•) *3 program,1636 MSC,Raleigh,-NC 27699-1636
12:Well construction method: 24c
AIR ROTARY' , r x , .
.For Water Supplya`nd Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push etc.) x .a f county environmental health.department of the county where installed N
FOR WATER SUPPLY WELLS ONLY + C
24d.For Water Wells.producing over 100,000 GPD Copy to DWR,C PCUA
PerrnitPmgrarn;.1611MSC Raleig14NC27699 1611"
13a.'Yleld(gpm) 3o Method of test A/1t' I I
7r
70%HTH Amount.- OZ DATE SITE VISITED:
13b.Disinfection type: _ G
f.
_�< VISITED BY: