GW1-2021-05355_Well Construction - GW1_20211013

t` _,�1�� iI II�I`T�7[; i�J��I��IY k tl✓t�jl'i o ;(�G�i`y�1'; For Internal Use Only:
A.Well Con Information:
14 (�0.�{Lln 14.WATERZONES
- _gc
Well Contractor Name
3 A}�]�- FROM TO DESCRIPTION
n 1.(`A 1 (u L t ft.
11 �
jj[OCesssing Vlll ft. ft.
NC Well Contractor Certification Number 1jt13[l+3t`OV)
15.OUTER CASING for multi-cased wells)OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASTING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnic(ton permits(i.e. /C,County,State,Variance,etc.) ft• s ft. in- e J Dn',) P�f
3.Well Use(check well use): ft. ft. V O in. K 4-
F7.SCREEN
Water Supply Well: R n
FRODI TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) �aesidential Water Supply(single) ft. ft. in.
❑IndustriaIlCommercial ((❑Residential Water Supply(shared) 18,GROUT
❑Irrigation ❑Wells>100,000 GPD FROhI TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 1-1 ft. 14 k P�J51 P0Vrr.J L4 10 q SS
❑Monitoring ❑Recovery ft 3 ft. Owl: Gmuf I�
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EIYIPLACENEENTN ETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal%eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type in size,eta
c �y ft. L�O ft. t
4.Datc Well(s)Completed: 7 Q a Well ID# 33. C. 0 ft. S02 ft. 6(%VV ft. ft. �Y
5a.Well Location:
on: P� OII2 .r
pA See, `�U�f13 -It 9 3y ft. ft.
•V.
Facility/Own, Name Facility ID#(ifapplicable) ft. ft.
9 �L b -f_)it to c e_ f/ eaQ ft. ft.
Physical Address,City,and Zip A,Da-esIJf i ft. ft.
21.REMARKS
County Parcel Identification No.(PN C
._\
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
\� if well field,one lat/lon is sufficient
V C d. g ) ``a 22.Certification:
�6.Is(are)the well(s): WPermanent or ❑Temporary Signaturi of Certillied Well Contractor Dat -A9
S By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
S 7.Is this a repair to an existing well: ❑Yes or Mo 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 record has been provided to the well owner
repair under#21 remarks section or on the back of this form. W
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.
drilled: 24.SUBMITTAL INSTRUCTIONS N
9.Total well depth below land surface: 5O,• (ft.) ,-
For multiple wells list all depths ifdiereni(example-3©200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
isb24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter: (in.) Bit Off: ,C60 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
t Permit Program,1611 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) Method of test: Q r n GYM
13b.Disinfection type: 70%HTH Amount: 1 OZ DATE SITE VISITED:
VISITED BY: V 6
Form GW-1-. - North Carolina Departmentof Environmental Quality-Division of Water Resources Revised 6-6-2018