GW1-2021-05580_Well Construction - GW1_20211013

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CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We11 Contractor Information:
T�rlt2on I ! ra win E'���e 14.-WATERIZONES
-�--r"• �7" FROM TO DESCRIPTION
Well Contractor Name
`�� d ft.
3 C)3 & A ��� 1 lde�5'z0 G ft. ZD ft.
NC Well Contractor Certification Number `$^P`O° Ot� 15-OUTER CASING 6FiHlti-6ged,4ells'ORLINBR ifo"licable',
YADKIN WELL COMPANY,INC. � t,(Z� FROM fr DIAAffTrR TEIGMUSS TRIAL
Company Name
t� 16.INNER CASING OR TUB1N . eothe'r`mahci6'sed4c o
2.Well Construction Permit#:19.5 11 f 0(2 W1 - 2 )2-k FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. / ( in. - �I
3.Well Use(check well use): ft. fr. O In• l-
WaterSupplyWell: F1tON! TO DIAMETER SLOT SIZE TZICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. n.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft In• Q
❑Industrial/Commercial Residential Water Supply(shared) IS.'GROUT two
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery 3 fr. a e- ft. , 3
Injection Well: J
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sf iF icable" '
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO RIAL EMPL MENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer '20:DRILLING,LOG'attiEbadditioniil;sheets if=necesso•'
FROM TO DESCRIPTION eolar,hardness,soiltroelc type,grnin size,etc.
❑Geothermal(I3eating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
( .� �01
4.Date Well(s)Completed: 7• / Well ID#f�I i 7
44- s3 ft. /023 ft. e4,1 10'7'e
5a.Well Location: Phone # 33C- -663t ft. ft.
ft. ft.
Facility/Owner Na/me Facility ID#(if applicable)
3 it
J ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) too
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _`r00 S�
(ifwell field,one lat(long is sufficient) / 22.Certification:
--� 36v 3 / sat 1 N 090 a '543 W — 9- 7-a
6.Is(are)the well(s): dermanent or ❑Temporary Signature of Certified Well Contractor Date
l� By signing thisform,1 hereby cet4�that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L�J'N, 15A NCAC 02C.0100 or 15A NC AC 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#21 remarks section or on the back of this form. -•F
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 CAW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBMITTAL INSTRUCT IIONS
9.Total well depth below land surface: 6)O 3 / (
For multiple wells list all depths ifdierent(example-3 00'and 1©100D f t) Submit this GW-1 within 30 days of well completion per the following: '
`J 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: C 0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 I
If water level is above casing,use"+" j
11.Borehole diameter: o (in,) Bit Off:Tr 76 711 24b.For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 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 WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 'S Method of test: Plk u 1 r I
a DATE SITE VISITED: ��� T �r-7i� u�' " Ar
13b.Disinfection type: 70/o HTH Amount: Z OZ
p,/� VISITED BY:— !: ��, s