GW1-2021-05269_Well Construction - GW1_20210503

�1,CONSTRUCTION RECORD f GW-)1) For Internal Use Only:
1.Well Contractor Information:
/ / G1 T Thji�/ /'/^Q(+✓n 14.NVATER ZONES i
Well Contractor
/Named FROM TO DESCRIPTION
30 � 1�3J 1 / !D ft. r7
iW ft. 1.411 ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul&eased,irells)OR LINER if a" livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNESS I MATERIAL
RIAL
fL
Company Name
' 16.INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: 4/erAF �11 7l /G d-X J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.&7C,County,State,Variance,etc.) ft. (f ft• /1 in-
3.Well Use(check well use): ft. I 1 ft. 6 in. U
Water Supply Well: 17.SCREEN
FROM TO D1A14IETER SLOT-WE THICICYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared)
@.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o tt. 3 ft. C S G d
J / p,
❑Monitoring ❑Recovery ? ft. ��
Injection Well: J ft, ft.
IF
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a'�livable) i^
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO TEAIAL EMPLACEMENT METHOD (�1
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20..DRILLING LOG attach"additional sbeets if necessai"
❑Geothermal 03eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type in size,etc.
�� �I / O ft. Cr ft. t
4.Date Well ppl s)Completed: ` `I G - ( Well ID#�rf -�C� 9 g ft. qo ft. � v/
5a.W�feell Locations: Phone # I33C-yeP-a l�L ft � ft.
J i x J !t !�,!rl r erg -w e ft. ft. .`
Facility/Owner Name /Facility ID#(if applicable) ft.
f.
Physical Address,City,and Zip fr• fr•
41AK 21.RE,MARKS 92A
,
County Parcel Identification No.(PIN) 6 Vsrn.SII4;
Iiii0C1:;31ivti `-- r{j0il
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: aB�
(if well field,one lat/long is sufficient) 22.Certification:
_3i L3, 7oq? N 7W,02 'I
6.Is(are)the well(s): WPermanent or ❑Temporary Signature of Certified Well Contractor Date
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 klo 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.
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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dolled: // 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b Submit this GW-1 within 30 d
(ft.) y P P a s`of well completion per the following:
For multiple wells list all depths if dierent(example-3Q200'and 2®100� g:
6 O 24a. 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
If water level is above casing,use"+"
11.Borehole diameter: (s (in,) Bit Off:jC, 0 7;J 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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departnmeht of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: CC!
Permit Program,1611 MSC,Raleigh,NC 27699-1611
� t
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: 4_4
�try�a Y� VISITED BY: V6 �
Form GWA North Carolina Deoartm nt of Environmental Quality-Division of Water Resources r t 1 •7 a Rericefi6-6-2018