GW1-2021-08126_Well Construction - GW1_20211109

WRIM CONSTRUCTION RJECORD(GW-1) For Internal Use Only:
I.Well Contraetot Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. 42.2
ft.
V41 Gpi.'
Z 4 S•a 91+�►
NC Well Contractor Certification Number ft' 7805 fc. 0f G'i
15.OUTER CASING for multi-cased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM I To I DIAMETER TffiCKNESS MATERIAL
Company Name
fr. I ft I J, in.
�� p 16.INNER CASING OR TUBING eothermal dosed-too
2.Well Construction Permit#: ! FROM TO DIAArr.TER T"T K 0S MATERIAL
List all applicable well construction permits(�e.fllC,County,Slate,Variance,etc.) `ft• fk G 1° Sole,;IVL /�
3.Well Use(check well use): fr. fk in. ( �•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER: SLOT SIZE THICKNMSS MATERIAL
❑Agricultural ❑Municipal/Public it. fr. in.!
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ft• ft. in.
01dustrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT V�J
Non-Water Supply Well: O ft 3 ft. HOW P q POUW A4
❑Monitoring ❑Recove
Injection Well: ry 3 fk 92 fr• Ouv-k Groat Vmeti S S
❑A uifer Recharge fr' fk
q - arge ❑Groundwater Remediation
❑Aquifet Storage and Recovery ❑Sty Barrier rSAND/GRA�VEL PACK if a licable
MATERIAL EMPLACEMENTMETHO❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control . ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothemlal(Heating(Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCM71ON color,hardness soiVroek typr,gmin she,etc
0 r
Q e
4 Date_WeII(s)Completed: �� 7 d Well W# — ft- _� 8 fr. Sy38 ft- '902 ft. ran
I
Well Location: ft fk
Phone #7vY•G -e1GlG
Facility/Owner Nafae Facility M#(if applicable) ft- fL
fL
Physical fk
_AAddress,City,and Zip T ft 44 21.REMARKS
County Parcel Identification No.(PIN) nu.
1 Li Y:I' �,�1•I I',1�i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
livl`C �.lhT;(`t,l �rlrccc;,;n,
(ifwell field,one lat/long is sufficient)
i 22.Certification: ;',r"
d
6.Is(are)the well(s): #ermanent or ❑Temporary Signatite of Ceitia Well Contractor Date Vl
r .:r
,'' By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 01C.0100 or 15A wrth �
NCAC 02C.0100 Well Construction Standards and that."copy a
E If this is a repair,fill out known well construction information in explain:the nature of the' of this record has been provided to the well owner
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For GeoprobetDPT or Closed-Loop Geothermal Wells ha'Vmg`th1'same You may use the back of this page to provide additional well conshnlcfion info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary. �y `s
drilled: 24,SUBMITTAL INSTRUCTIONS 0
9.Total well depth below Iand surface: t
For multiple wells list all depths jf different(example-3@200'and 2Qa 100)1 �f Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to of casing: 24a• For All Wells: Original form to Division of,Watei Resources WR,
P g• (ft) Information Processing )
Ifwater level is above casing use"+" g Unit,1617 MSC,Raleigh,NC 27699=1617;,,,.,•. i
11.Borehole diameter: Bit Off: . 24b.For Injection Wells: Copy py to D WR,Underground Injection Control'(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method. AIR ROTARY
e.auger, cable direct push etc)
(r' ger, , , . 24c.For Water Supply and Open-Loop Geothermal Return Wells -Copy to the
county environmental health department of the county where installed; at
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing ovl a 100 000 GPD Co to D
13a.Yield m Permit Program,1611 MSC,Raleigh,'NC 27699-1611 CCPCUA
(gp ) Method of test: A,I!p R
13b.Disinfection tYP •e• 70%HTH Amount: 31 OZ DATE SITE VISITED:
VISITED BY:�IM _ I