GW1-2021-05267_Well Construction - GW1_20210503

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L tCONST UC iTION Ri tCOR91 dGW_Di For Internal Use Only:
i.Well Contractor information:
A++►ISM/ $ ro W^ 14..WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ^ q I
7O fr, ft.
3 y 36A 14Qo ft. .4sa ft. ci,,j pv
NC Well Contractor Certification Number el Oq 15.OUTER CASING fo m INE r ulti cased wells)OR LR if a livable
YADKIN WELL COMPANY,INC. MA L L FROM To DIA11fETER CIQtlEss IYrATI
` '� ft.
Company Name a:� j C^.t��Sl
Il'`3i3OII V t c.r j;0i1 16.INNER CASING OR TUBING(geothermal closed-ldo
2.Well Construction Permit#: w{)t� ` FROM TO DIAMETER I THICKNESS I MATERIAL l
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft' i 4 ft' 6 S/ in. O. ,S S/1 GG IV $f�
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well:
pp Y FROM TO DIArYIETER SLOT SIZE THICKNESS MATE
❑Agricultural ❑Municipal/Public it. in•
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO rVIATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. 3 ft. sa�' p6'Av J -�
❑Monitoring ❑Recovery 3 ft' Z 2 ft• &Aa4ter $1trM i vnt
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation r ft V/M
19.SAND/GRAVEL PACK(if aptAicablef
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EN PLACEMENThiETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type,gnin sue,etc
❑Geothermal(IIeating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. ft. _ S
4.Date Well(s)Completed: q (y_.2 i-.21 Well EN _AV- ft -2 g' ft. w
5a.Well Location: Phone # 33' I Z$ft. .270 ft.
.2 70 ft. 3 I o ft AQ S6 G „1 to
Facility/Owner Name Facility ID#(if applicable) 310 ft.
L o kL4h o nt go 140 It. jj 5��1' G•a�ik,
Physical Address,City,and Zip ( 0 l C4L4
21.REMARKS
rills �iCt.r _ F r�' t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: te4h eP P1 O G� keO S
(if well field,one lat/long is sufficient) 22.Certification: OF hko�S-
6 N el O-S• OZZZ. W -1%'1-0[9
6.Is(are)the well(s): ;Vermanent or ❑Temporary Signature of Certified well Contractor Date
i
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 00 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 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 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.SUBMITTAL INSTRUCTIONS
l
9.Total well depth below land surface: (ff) Submit this GW-1 within 30 days of well completion per the following:
if d
For multiple wells list all depths ifferent(example-3 t@200'and 2@1001
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"+" .
4
11.Borehole diameter: 6 (in.) Bit Off: 1 24b.For Injection Wells: Copy to bWR,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 pusb,etc.) county environmental health department of the county where installed
1
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: lf,� � -q
13b.Disinfection type:
70%HTH Amount: �j OZ DATE SITE VISITED:
C ' L�-
T H VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ,�t (^ Revised 6-6-2018 n n