GW1-2021-05574_Well Construction - GW1_20211013

)N 1REODRD(G'V-1) For Internal Use Only: f
1.Well Contractor /9
r Inforrmation-
Gy '-T- hQ.V�/ 0w .-.1` 14.WATER ZONE,S
FROM TO DESCRIPTION
Well Contractor Name P
3 0 3 �A � � 3,f'ft. 3 7 ft. '
'� ft. ft.
NC Well Contractor Certification Number C� �r���� 15.OUTER C or multi-cased w R LINER if a ticable
YADKIN WELL COMPANY,INC. �(OGe:`O� FROM Du rffit IavEss RIAL
Company Name
p y 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: W ) - ' f FROM To n THICUCC,SS nu
TERIAL
List all applicable well construction permits(Le.UIC,CovnFy State,Variance,etc) � ft. ft. I j
fq in CJn`7
Air
3.Well Use(check well use): 17.
ft. to
Water Supply Well: FR SCREE EN
ROM TO DIAMETER' SLOT SIZE THICKNESS MATERL4L
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) kfesidential Water Supply(single) f tt. inJ
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .00
❑hTi atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACENTENT METHOD&AMOUNT _
Non-Water Supply Well: ft. ft. h �r4vi•
❑Monitoring ❑Recovery 3 ft. aJ ft t i v
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACE NT METHOD
bAquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM To
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) DESCRIPTION color,hardness,soil/rock e . n size,etc
W
C/ 2 ft. ` fL
4.Date Well(s)Completed: / -"7 Well M# -� J /011 ".
5a.Well Location: Phone # M Ate -1442- ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
i
t cos yi'lle� .2 7oSr ft. ft.
Physical Address,City ft. ft.
21.REAIAgRKS
Coun Parcel Identification No.(PIN) +1"I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certifieatio
3�C' 7.1 N 2 F, W �- 23 a 1
Signature of Certified Well Contractor Date
6.Is(are)the well(s): permanent or ❑Tempora ry
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 1 SA NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a ropy
If this is a repair,fill out known well construction information&d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 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 (V
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages if necessary. (01
drilled: l 24.SUBMITTAL INSTRUCTIONS N
9.Total well depth below land surfacer (ft.) Submit this GW-1 within 30 days of well completion per the followiDg:
For multiple wells list all depths if different(example-3Q200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
10.Static water level below top of casing: Information Processing Unit,1617i MSC,Raleigh,NC 27699-1617
if water level is above casing,use // �*
11.Borehole diameter: fO (in,) Bit Off: (9 -10 b ! 24b.For Injection Wells: Copy to DWR,Undergropnd Injection Control(IUC)
Program,1636 MSC,Raleigh,NC17699-1636
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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinP over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1� 5 Method of test:
o Ol DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZ
VISITED BY: ��>� 1�1�a.\ V
...... _ wT-ai.r+....,c r1e..e...,...,s'R....:.,.,.-tal duality-Nvieinn of Water Reennrcr_a Revised 6-6-20118