GW1-2021-08124_Well Construction - GW1_20211109

QRD�(a�-�� For Internal Use Only:
��ntractor Information:
'1
14.WATER ZONES
FROM TO DESCRIPTION
Well CuntractorNam .ft e
5-7k/f ft. ft 1� /
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased we➢s ORLINER rf a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICIQIESS MATERIAL
ft ft. in.
Company Name 16.DUO R CASING OR TUBING eothermal closed-loop)
2.Well COnatrnction Permit#: FROM TO DIAMETER TMCIINESS MATUM&L
List all applicable well construction permit ie.UIC,CountAIA y,Slate,Variance,eta) ft C( 1 f-m. SID(Z 3•f 1_V'(d
3.Well Use(checkwell use): t ft. in.
17.SCREE N
Water Supply Well:
FROAS TO DIAMETER SLOT SIZE THICfOYESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. in.
Oluduslrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT T4ETHOD&AMOUNT
Non-Water Supply Well: ('� It- s P IL /�h .4 �i►`�
❑Monitoring ❑Recovery fL ft pn-�UO J
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK dapplicable)
❑Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) , ❑Other(explain under#21 Remarks) FROM TO DFSCRTMON color,hardness,solVmLktypS grun sim etc
y 0 ft. a ft. -50 ``
4.Date Well(s)Completed: 0 D : Welim# " (� ft 'Sff?l� ft' eq� r sorJke
5a.Well Location: hone # `7G�3 7�',r.3 fL +a
ft fL
Farr'ty/OwnerN a ,I Pacil IC*(rf applicable) ft ft
,14
�C� I Ck- JtO�/✓j �s C641 ft. ft
Physical Address, ,and Zip ft ft
A21.RRMARK.4
county Parcel Identificaflon No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or deciimal degrees:
(ifwell field,one IaMougis sufficient) mil$ (/,� 22.Certification:
36" 2-)t. �14'r N �v W /0417
6.Is(are)the well(s): EWermanent or ❑Temporary S' of ltified Well Contactor Date
By signing thisform,I hereby cerhfy that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or l3Pto ISA NCAC 02C.0100 a•1SA NCAC 02C.0100 W ronstruction Standards and that a copy
If this is a repair,frll out brown well construction information and explain the nature ofthe of this record has been provided to the well owner � ,P 1/),
repair under#21 remarks section or an the back ofthisform. 23.Site diagram or additionallwell details: n
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same �You may use the back of this page to provide�tlA41onal riZ t ction info
construction,Only 1 GW--1 js needed. Indicate TOTAL NUMBER of wells (add'See Over in Rema Box).You may also attach atiditio rf necessary.
drilled: � 24.SUBMTrrai.INSTRUCTIONS��,� OVVR SECTION
9.Total well depth below land surface: 2 (ft.) C�'�T�O��P�OCESfSI�;��f
For multiple wells list all depths!f dfemnt(example-3Qz 0'and 1®100D Submit"this GW-1 within 30 days of well completion per the o �T
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levkl below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level/s above casing use"+"
Bit Off:_J--.-7--?'-- 24b.For Iniection Wells: Copy to DWI;,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
EDisinfection
UPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
/L Method of test: �} /L�e
70%HTH OZ DATE SITE VISITED: '`,'2 ss-it? ��ab
type: Amount: _
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