GW1-2021-04220_Well Construction - GW1_20210415

„_. W EILIL CONSTRUCTION RECORD(cGW-1) For Internal Use Only:
�1.Well Contractor Ymfo mation:
j`_ :•]4'•WATERZOLVES' ``._ - •, .
Well ContractorName FROM TO DrSCPurTION
3 () 3 6 A �,rrt 2021 2�t4 ft ,tro gyp'}`
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NC Well Contractor Certification Number ft ft r1rn�C� •
g S.OUTLtIt.'(.ASING for-multi=eased•�dell3'ORL1NEIt'ifii"'cable'=..•.;.:-_.. � t
Yadkin Well Companyn,, c.Yt1011 FROM I To DMWna I.TMCMMS MAMMAL
Company Name ft.
•:16:DVNER CASIKGrOIt TIIBDAG 'eotIie�a-I closed lcu = - '” '- '
2.Well Construction Permit#: FROM TO DIAMETER TffiCENESS •MATEMAL iJ
List all applicable well construction permit (i.�G County,State,Variance,etc) ,f, t ft q2 ft G m• O,r p8 A G7s+4/ • J" ,f�4
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3.Well Use(check well use): it ft in
Water Supply Well: FROM TO Dreutrtx r M SLOTS THIc%1vEss Irvrax>]uAL
F Agricultural nMunicipal/Public g, t in.
_Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft
IndustriaUCommercial [DResidential Water Supply(shared)
'18:GRODT �'
Irrigation FROM TO I MATERIAL EMPLACEA EWD1=OD&AMOUNT
Non-Water Supply Well: ft ft to 4 C rtA G�A w J
Monitoring DRecovery ft.
Injection Well ft ft
_Aquifer
Re charge �GroundwaterRemediation
19:56NDlGRAVEL'PACK ffa' Iirahle
Aquifer Storage and Recovery [❑ISa11n1tyBaRiei FROM TO MATERIAL EMPLACEM1D7NTMETHOD
_Aquifer Test O Stormwater Drainage ft ft
Experimental Technology OSubsidence Control t ft
—'Geothermal(ClosedLoop) MTracer I 20:DRIMINGI.OG 3t&&--aa3it1onslsheetsifneccis"
_Geothermal(Heating/Coolmg Retrnn) (—Other(explain under#21 Remarks) FROM I To DFSCREPITON(color,hardness,soil/mck G a,o sbT etc)
ft ft
4.Date Well(s)Completed: — r Well ID# ft ft
5a.Well Location: Phone number--73(. jl: it ft.
f_J' ft ft.
W�(A-c.V �i Gf�
Facility/0,AmeerNa(m'e FaciilityyM#(ifapplicable) f ft ft
Physical Address,(Sty,and Zip `F ft ft
CL C .21:-RRN1AR7K';
py�,/
County Parcel IdentificationNo.(PII� -Cal C!19Je_J ,. 40
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r �r ✓� - t' !r(+4�
(ifwell field,oohnyelatAongiis sufficient) 22.Certi$eatioII: „ 14,
�� �1►� �! Z N J 2A W
6.Is(are)the well(s)MICmanent or MTeroporary Signature 6fUe'rtilied Well Contractor, Date
By sigl»ng this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an effisting well: [ es or DNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out Mourn well construction information and explain the nature ofthe copy ofthis record has beenprovided to the well owner.
repair under#21 remarks section or on the back ofthis farm.
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 site details or well
construction,only I GW-1 is needed- lndicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:* I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:-2- ��a (ff.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths if different(example-3(a)200''and2 a 00) Construction t0 the following
If rioter level is above casing,use
10.Static water level below top of casing: ((d ' (ft.) Division of Water Resources,Information Processing Unit,
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1617 Mail Service Center,Raleigh,NC 2769916I7
11.Borehole diameter: 6 (in.) Bit Qrf 24b.For Iniection We In addition to sending the font to the address ut 24a
above,also submit one copy of this"form within 30 days of completion of well
12.Well construction method:
(ie.auger,rota cable,direct push,etc.) - construction to th
ry, e following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEI I,S ONLY: 1636 Mail Service'enter,Raleigh,NC 27699-1636
'l e
13a.Yield(gpm) `+'y Method of test: ��Sr' Ai f 24c.For Water Supply&Iniection'Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: CUPS completion of well construction to the county health department of the county
where constructed- I
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Fomi Gw-1 North Carolina Department of Envimamental Quality-Division of Water Resources E Revised 2 22-2016
Fite Site Visitt6d .' '`]•20 bye ! t+
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