GW1-2021-05573_Well Construction - GW1_20211013

VEJEL CONSTRUCTION RECORD CORD (GIV=1) �� For Internal Use Only:•
1.Well Contractor Information: $ b`
A14 7144,1/V dJ/ CJ W 1�{.\ 14. ATER ZONES
t `ter'z TO DESCRIPTION x �
Well Contractor Name ��,\ J OQr�c��r ;V ft' a'3;� ft
�.Jr. 4
30 3 6 � `°oc� 36 3 ft. 36.3" ft J,601
t
NC Well Contractor Certification Number
15.OUTER CASING for uiulh resed,wells OR•LIlVER tf a hcable 5 tea'r
YADKIN WELL COMPANY,INC. FROM O D R r Tffi S L S R�I^AyL�i
Company Name — x z
Yl.�t.\ ,� &K
-° Q��®`� 16.IIVIVER CASIIVG OR T[(BING- eothermal closed loo
2.Well Construction Permit#: (1 Z36�® �'a FROM To.: DIAML+TER sMAT
tfficlavlesERIALR'�A9Z.W
f 'rAM 3 i
4List all applicable well construction Permitsts(Le UIC,County,State,Yarionce,etc �i ft
ft, ft
3.Well Use(check well use):
17.SCREEN . .
Water Supply Well: FROM TO I DIAMETER,L SLOT SIZE ; CIQYirSsa.
❑Agricultural ❑Muaicipal/Public
❑Geothermal(Heating/Cooling Supply) %&,idential Water Supply(single) t. I tt rn 1 r 4' MIMI
"
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Wells>100,000 GPD FROM TO. �MATERML ;4r�EMPLA:CEMENTNMTHODi
&IAMUUNT
01rri ationr4J rl r b
Non-Water Supply Well: ft. 3 ft° 1'iste.� � �i6w6w�
❑Monitoring ORecovery 3 it ft .� .S �P
InjectionWeli: ft ft a� erF,r,r
❑Aquifer Recharge ❑Groundwater Remediation 19:SANDlGRAVEL PACK-'if a" livable _ I "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO a' ~MATERIALS ti iIEMFLACEtVbNT.TSElHOD
❑Aquifer Test ❑StormwaterDrainage _, >
��r xsr
❑Experimental Technology ❑Subsidence Controlt " w�kR hr
❑Geothermal(Closed Loop) ❑Tracer 0.DRILLINGLOG(if di" sheetfif niM,a
FROM TO, :'�•.'� ;DESCRIPTION color liardnes"s oiVmck•:"�iosiu`fiett
❑Geothermal(Heating/CoolinggReturn) ❑Other(explain ft)
WellID# A under Rema
Ao
4.Date Wells)Completed:
sa.Will Location Phone#
3 � fr4 ' # iSy
za
• s *ft
«, i` .
Fac$ity/Owner N'am//e fiv-
Facility M#(if applicable) ft ;,„ n sew `
a s ft 7,7
ft� a, 11 AI S
Physical Address,City,and Zip
�J,,'j ♦� 21.REMAWKS -r ..` _
County Parcel Identification No.(PIIQ)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f y �
(if well field one laUloag is sufficient) 22.CerttSeaiiOn" kl
N �d! W f7 x^ }' s�r,;�) spa,c •.��' I
srgnatd6 of Certified W Conhactor :r `. �' Date
6.Is(are)the well(s): ermanent or ❑Temporary
By sigriirig this foi m,I heieby certify that the well(i)was(were);constructed in accordmrce with
15ANCAC 02C 0100 or 1A'NCAC 02';0200 Well Const•"n`tctron Stan d lhal a copy
7.is this a repair to an eidsting well: ❑Yes or �l!`to of this record has been provided to the well owner r a
If this is a repair,fill out known well construction information and erplain the nature of the
repair under#21 remarks section or on the back'of thisform. 23.Site diagram Or additional well details>`
e x aya:.° a y t..
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pagM to provideddiowell construction info
construction only 1 GW-1 is needed. Indicate TOTAL 1VTJMBER of wells (add See 0"?•in Remarks Box) You may a9so attach additiona��netsnssary.
drilled: 24.SUBMITTALL INSTRUCTIONS #
9.Total well depth below land surface: (ft j withi l'
Submit Ibis GW 1 n 30 days of well co "th�mplehon�pere following:
�
For multiple wells list all depths indifferent(example-3©200'and 2@1001 " I }e t 4
24a. For All Wells Origmal form to Drviss on of.Water Resources (DWR),
10.Static water level below top of casing:_ (ft•) Information Proaessmg Unrt,16171vISC Raleigh,NC'27699-1617
If water level is above casing use
11.Borehole diameter: (in,) Bit Off: S�. I 6 lls:Copy t DWR,Undergro�und�Injectioa<
24b•For Injection We
Cont;ol.(lUC)
Program,1636 MSC Raleigh,NC 27699.1636 t
12.Well construction method: AIR ROTARY t
24c.For Water ��� r
Supply and Open-Loop GeohermalrReturn.Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environ hental healtii department of the countyrwher installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wehi'producinglover 100,000`GPD ,Copytto DWR;CCPCUA
• Permit Program,=1611 MSC Raleigh'NC 27699 1611 R
�a 13a.Yield(gpm) �V ® + Method oftest: rt Ai
n 70°/ HTH a OZ DATE SITE VISITEDs: d ZIr jC" c
13b.Disinfection type: ° Amount:,
VISITED BY "?
4