GW1-2021-04221_Well Construction - GW1_20210415

i-j ( .� &I- Ui N�l Ii?{C�j�-;rRIli,i i-;,:r,,�1 .f GWt II For z t +•
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J.Well"Lon.i:•aetorllrJ,la:i
e e 14.NVATER ZONES I
FROM TO I DESCRIPTION m
Well Contractor Name
o?11 ft.
a
ft. ft. I
NC Well Contractor Certification Number J 2021 15.OUTER CASING(for multi-cased wells)OR LINER if applicable) C�
r l FROM TO DIAP.'IETER TffiC[4VESS NIATERJAL
YADKIN WELL COMPANY,INC. {{y�11 ft. ft. in.
Company Name r.^r r t ` - t
P Y �rilvt{ii cu�
l��� � ,c�{?y�y�/���'n+y "1 16.INNER CASING OR TUBIPIG(geothermal closed-loop) -{
2.Well'Construction Permit#• k � a°� P/ ^"vG FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,Comity,State,fariance,etc.) in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAN TER SLOT SIZE I Taliciff4ESs I MA RLA
❑Agricultural ❑MunicipaVPublic ft. ft. io• a�
❑Geothemral(Heating/Cooling Supply) CL Residential Water Supply(single) fr. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 13 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL ERIPLACEMEN T METHOD&AMOUNT
Non-Water Supply Well: b ft. -7 � -e
OMonitoring ❑Recovery J ft. ft. �-
64
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANS/GRAVEL PACT{(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROn4 TO MATERIAL E-P%PLACE-MENTREETHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. 1
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FRO11•I TO DESCRIPTION(color,hardness,soiltrack type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft. `7
�y ® p� p
4.Date Well(s)Completed: OB ® Well IdD# ' '° �m��0 ft. ft ` ��
Sa.Well lLocation: phone # ® `��'y. ` 6y��� 44
ft l) ft. V 6- -V
��meL�iA 6R S� v//es/
lC V
1 �
d
Facility/Owner Name ` J F Facility _#(if applicable) ft' ft. _ 2- hh a
G
Physical Address,City,and Zip ft. ft t
21.RETYLARKS
`J� �
County / Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
�llat/long is sufficient) 22.Certification:
aP ry signature of Certified Well Contractor' Date
•,E1Pe
6.Is(are)the well(s) rmanent or OTempora J
By signing thisform,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IkNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy C
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 tinder#21 remarks section or on the back of this form. 23.Site diagram or additional Well details: C
tr
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.SUBM][TTAL INSTRUCTIONS
9.Total well depth below laird surface: 16 J'-(ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dQerent(example-3Q200'and 2 u@100D
d 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 J
If water level is above casing,use"+" cu
11.Borehole diameter: (in.) Bit Off: /® 24b.For Injection Wells:Copy jto-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
} Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
u DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZ
VISITED BY:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources {�� Revised 6-6-2018