GW1-2021-04219_Well Construction - GW1_20210415

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�)I I T _ `J _:tL 1�T 1ai _ _ (_ Jn1 n or Internal Use Oiily: _
tl.Wef3 Go�l,•actor lu�or;rai:ioaa: - �
) r S 14.VYATER ZONES l
Well Contractor ame R ].,'j FROIYI TO DESCRIPT30Pi
q L17 ft. 7 tft. S f (/ram'
NC Well Contractor Certification Number r q 021
F�+ J L 15.OUTER CASING(for multi-cased wells)OR LINER if a le C
YADKIN WELL COMPANY,INC. FRaM To DIAMETER THICKNESS MIATEREAL
f�,►17g OKI, f£. ft. in. G
Company Name C^r1�:3 s�'l vim
3 /�/�l`� v�R��CtfOO 16.INNER CASING ORTUBING Ieothermalclosed-loo )
�[3 7 �,' FROM TO DIAMETER THICIOYESS MATERIAL
2.Well Construction Permit#: GG
List all applicable well cmustntclion permits e.UIC,C.ou ly,State,Mariance,etc.) /ft. 1ri+u• Q u pvc
3.Well Use(check well use): L ft' ! ft' in.
Water Supply Well: 17.SCREEN
FROM TO DIAMIETER SLOT SIZE THKK LESS D9ATERL-IL n
❑Agricultural ❑Municipal/Public ft. ft. an,• I //
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. iq• �/�
❑Industrial/Commercial ❑Residential Water Supply(shared) 13 GROUT
❑Irrigation ❑Wells>100,000 GPD FROMI To MLaTEMAL EMIPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, �• ft. _! �r
❑Monitoring ❑Recovery ft. ft. g(-7•3�vi
Injection Well: Cj
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK(if applicable) 1
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENER CEMIENT B•IETHOD J
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) MON ft. TO DESCRIPTION(color,hardness,soiltrock type,griin size,etc.)
4.Date Well(s)Completed: �1 Well l3D# �^^ �3 ft.
5a.Well Location: Phone # ��. 3 o'ft. rho c .*ewe
S a b o h �f �v+o �� 3 77-" y/lo
V •ft. �a�.l r �.�.•
Facility/Owner ty/lr Owner Name �/ n n Facility ID#(if applicable) `6 ft. (pQ�•ft. �{�� J
tv1y a 11 L W i'C/. Cl-j tvl�*ek 41 A-, Pt`"/1
Physical Address,City,and Zip NC,
21.REMARKS
Q
County Parcel Identification No.(PEN) v + (
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:3 l0 d !S 4� N Y6 �`f'i / S W 1 —`,,41)
6.Is(are)the well(s): (.Permanent or ❑Temporary Sign of Certifi(4;VreH Contractor Date
By signing thisform,I hereby certijy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Mo I5A NCAC 02C.0100 or 1 dA NCAC 02C.0200 Well Consbirction Standards and that a copy
If this is a repair,fill out Iworvn well construction information Ad 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
construction,only I 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
9.Total well depth below land surface: d (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2Q1000
(ft.) 24a. For All Wells: Original form`to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" //
11.Borehole diameter: (in,) Bit Off: to.07 7 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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWI?,CCPCUA
t (� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7)_ Method of test: ( C
13b.Disinfection type: 70%HTH Amount: 1 OZ DATE SITE VISITED:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2618 -�nJ