GW1-2021-04223_Well Construction - GW1_20210415

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(GW-1)
For Internal Use Only:
1. WellllContractor Information: }�
,/� ! 6 l It t% Lo/ U r u (0,
Well Contractor Name
3006A
NC Well Contractor Certification Number
YADKIN WELL COMPANY, INC.
Company Name iF,e
RE
p\•r i ZOZ1
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(r Clii� CI;OB
2. Well Construction Permit #: FM t'i i ) 3 2 - 2 J2
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
I ' esidential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells> 100,000 GPD
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 3 i Well ID# A Ao - 7- 2.V
5a. Well Location:
S&irIF s i/jefelate Ir
Facility/OwneiName f
Phone #
Facility ID# (if applicable)
13767 ( c ,ti t tit itt 1` k;A_;r-� He,- a27053
Physical ddress, City, and Zip
tit RI -41
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3C 6K, R. N s� • y3. /2 f' W
6. Is(are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: [Yes or IrfrNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #2i remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: It %
9. Total well depth below land surface: / 3 0 S
For multiple wells list all depths if different (example- 3 a 00' and 2 a 100')
(ft.)
10. Static water level below top of casing: 8� (ft.)
If water level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method: AIR ROTARY
(i.e. auger, rotary, cable, direct push, etc.)
Bit Off: - ' 08
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) e2/ Method of test: a tl,
70% HTH
I/ OZ
13b. Disinfection type: Amount:
14. WATER ZONES
TO
DESCRIPTION
�' e
ft.
IFq�I
Be, ( ft.
(fat" k l C
9 6 0 ft.
I on ft.
M' ( 4-;;' i ` L S.,-4} Fr�,c.,,c x 4)
15. OUTER CASING (for multi -cased ; elis) OR LINER (if an' licable)
FROM TO
DIAMETER
CTcNESS
`
MATE
ft,
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
14 ft.
/002 ft.
6 14, in,
Mg - I
PVC
ft.
ft.
in,
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICI MESS MATERIAL
ft.
ft.
in.
/
/
f//
ft.
ft.
• in•
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
aft.
3 ft.
me-i`fa 4 lc t 4'
s' 6't rr,'i e 3 /a,
ft.
ft.
- J
6iti' o4 7I', SIt„
r
93
, q'i t,,n
ft.
ft.
f�
/ Ce
74)
19. SAND/GRAVEL PACK (if applicable) v e '/
FROM
TO
MATERIAL
EN•IPLACENIENT METHOD
ft.
ft,
ft.
ft.
20. DRiLLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
D ft.
5-0 ft.
SOLI
5-0 ft.
qv ft.
�+ JJ
grin. / /tJ CY /Sr0 fnri N eA 4
qv,ft.
tl t� ft.
►gyp,°Ito
N�,rsc/
GU ft.
IiU7 ft.
/��
�OT'4 G►�'INT .
700 ft-
1. So; ft-
c r r
il1.1Q 6Rtnilt, 4 J&I'�- Frr3c&^t,3
ft,
ft.
ft.
ft.
21. REMARKS
1Frat.kLj e LLIb r'/0 t I
i
idol iIwo s' > I ts; °Prot- <P0000s) Fc ugs-T
6O - ET, , pse
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22. Certification:
3-013 al
Signature of Certified Well Contractor Date
By signing this form, I hereby cerl('Ihat the well(s) was (were) constructed in accordance with
I SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a cony
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construciion info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary .
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Colt' to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPIID: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
DATE SITE VISITED: ..3 ` 5 " 21
cithr vit.*
VISITED BY: 0 5