GW1-2021-05266_Well Construction - GW1_20210503

- + L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
�ti Q.L✓ L�/UW/1 14'WATERZONES ',:J I
We1lContractor Name FROM TO DESCRIPTION _
� fr. � ft.
3() 3(. A 2qs- ft. .2((6 fry
NC Well Contractor Certification Number 15.OUTER CASING'fonmulti=caled`wells:OR',IsiNER if a licable 1
YADKIN WELL COMPANY,INC. FROM T DIAMETER SS MATERIAL
ft. n.
Company Name r+ C.- b-r l- 7 J7,3®
o S .N A 16.]NNER.CASING OR TUBING,t eother'inil,ticsed=loo
2.Well Construction Permit#: 0'7 f-I A-2 FROM I TO I DIAMETER I TRICKINESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc..) ft. d ft. 6 1 , in. f
� C.r
3.Well Use(check well use): ft. fr. in.
Water Supply Well: 17.SCREENa, °
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. 'in.
❑Geothermal(Heating/Cooling Supply) 64sidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:"GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMLNT METHOD&AMOUNT
Non-Water Supply Well: tt. R. '4.
❑Monitoring ❑Recovery ft. 21 ft. Cr
Injection Well: �~ �u
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAY.EL"P.ACK if>a"olicable "'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL J.EMPLACEMENT MMTHOR
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRiIiLING LOG attach ddditionalslfii 'if necessa'
FROM TO DESCRIPTION color,hardness,soil/roelc e, rain size,etc.
❑Geothermal(I4eating/Cooling Return) ❑Other(explain under#21 Remarks)
41
Q(-Tv-
1e
�7 ft.
4.Date Well(s)Completed: - �9-z L Well M. ,1-'" ���� /2- ft' ar
!r f" /yJ!�,( ,` S',
rnd
5a.Well Location: Phone 3 , - 3� ft. 3o ft. G ��
7 6m FettA k
Facil ty/Owner Name
/` (� Facility®ID)#('if-aapplicable) / ft. ft.
2f a 2 r7G.ti�ht Cv-e Q 4C u K!y f BJ h�1►�J ft. ft.
Physical Address,City,and Zip ft. fL MAY X 3 2021
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21.REMARICS
nty a
Cou Parcel Identification �Pfcr1. 3tlon 11"ronesliltf] 'i11;
v J . t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loon�•g is sufficient) 22.Certifieaf on'
30 0:5, V�3 �/ -N 90 ,) f, C / 1 W _ 1 _ a2
6.Is(are)the well(s): dermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1 hereby certify that the well(s)was(were)constructed in accordance With
7.Is this a repair to an existing well: ❑Yes or NN110 15A NCAC 01C.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 921 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box):,You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 C) (ft.)
For multiple wells list all depths ifdifferent(example-3Q200'and 1®100') Submit this GW-1 within 30 days of well completion per the following:
i
0 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
Ifwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: 4, 067 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.anger,rotary,cable,direct push,etc.) county environmental health dep,"ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
f r• Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) } Method of test: Hai
70%HTH OZ DATE SITE VISITED: I 2-1 (tiL
13b.Disinfection type. Amount:
VISITED BY: V�s f ®� .4 GJe,
TIA
Form GW-1 North Carolina Department of Environmental Quality-Division of Wa Tr Resources 1�t r Ic_C- J)d Revised 6-6-2013