GW1-2021-05576_Well Construction - GW1_20211013

X.Y•�' 'fit!` N 11,1�EC 1TION RECORD(GNV-1) For Internal Use Only:
I.Well Contractor Informntion: 0.
/'/ 74 /` I.v/'� )'� 14.WATER ZONES
Well Contractor Name
t,� p' ROM TOr DESCRBTION G
90.364 OC\ � J 5�,t��� SJ it IU � ft. A /'s q ,s4d
NC Well Contractor Certification Number „',��Cori" R eo ft. ��' ft. "`' `�y " g.f(
�,Se ACJP' 15.OUTER CASWG forniulti-rased wells OR LINER(if alp) livable
YADKIN WELL COMPANY,INC. §G` Q�� FROM To DUMETER' CKNESS MATE
Company Name Yq4-sm✓J%- `Z ` ft.
6.INNER CASING OR TING othermal closed-loo
2.Well Construction Permit#: eV ��Z G�3»'i�� ( FROM TO DIAMETER TffiCIavESsI MATERIAL
List all applicable well construction permits ri.e.b7C,County,State,Variance,etc.) , ft. P- ft' 11 m. _.l
3.Well Use(check well use): ft. V ft. in.
Water Supply Well: 17.SCREE FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public tt. ff. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft to Q
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Ir igation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD A AMA-
Non-Water Supply Well: ft,
❑Monitoring ❑Recovery ft y
Injection Well: J�-
ff.
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.SAND/GRAVEL PACK(if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL FEMYLACEKENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessaTy)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/racktyp4 .'n sae,etc.
A& ft.
4.Date Well(s)Completed: q' 17- 2-1 Well ID# -65-3 0 7 Lei -
ft. aI A ft
611164,1 Ile,
5aa.Well Locatio�n: Phone #:,y�,- Sd�`� �,g;S" ft. �
Rabe 4- -/ i(�v sA�e ft. ft.
01
Facility/Owner Name Facility ID#(if applicable) ft. ft
/IK. Ps+4 � ft ft.
Physical Address,City,ang Zip fL ft
kl v, 21.REMARKS
County Parcel Identification No.(PIN) t%
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M 6
(ifwell field,one
Plat/longis sufficient) ec�L 22.Certification,
360 t%. I-A N 90 7- -7-73 W e
6.Is(are)the well(s): Wermanent or ❑Temporary Signatare,of Certified Well Contractor �® Date L
-_! By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ISO 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 retard has been provided to the well owner.
repair under 421 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
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.
filed' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: k`1 � (ft.
For multiple wells list all depths if dfferent(example-3@200'and 2 a@1001 ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
-S-0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaier level is above casing,use"+" (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: i 9.ax 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health departr itent of the county where installed
FOR WATER SUPPLYq WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) / Method of test: /`�� Qt f Permit Program,1611 MSC,Raleigh,NC 27699-16114*t !�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: �- `/'- 2A ��'/►'tc »`
Uri r•a-
VISITED BY: