GW1-2021-00115_Well Construction - GW1_20211109

W1E11,CON T1Ti'UCTION RECORD (GIV-1) For Internal Use Only:
V.Well Contractor Information:
ate©kln VWATERI ZONES
TO DESCRIPTION
Well Contractor Name ft 5' .svl 73 ft. 1O
NC Well Contractor Certification Number . CASING for multi-rased wells OR LINER if applicable)
YADKIN WELL COMPANY,INC. FROM T D THICKNESS MATERIAL
L•q $ in.
Company Name 3 °j�� 7�t�m 3 16.INNER CAS NG OR TUBING eothermal closed-loop)
2.Well Construction Permit#: PAW L. 202 1 ® 1 q-Y.z FROM To I DIAMETER THIcicirss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) + / ft' 7' ff V14
m.
3.Well Use(check well use): ft• ft. in. _
17.SCREEN
Water Supply Well:
pp Y FROM TO DIAMETER SLOT SIZE THI S MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. in. PO
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. ft. A� A hfB Z/
❑Monitoring ❑Recovery 3 ft. *Z 1 ft• ¢ & ^f-
Injection Well: ft. ft. 01
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMLTHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft.
11-10,
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck e, ain size,etr-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under
�#21 Remarks) ft ft
°4.Date Well(s)Completed:a�a�Well ID# A AQ—7®-3 oo
ft Z ft'
5a.Well Location: Phone # 95-b-7/ fL fr.
/V�r��(T°c�r�i ' M•f��4 ft. ft. ,
ft, ft t• F e ,
Facility/Owner Name Facility ID#(if applicable)
(/VQQ /&&h A t A QJ ft. ft.
NOV
Physical Address,City,and Zip ft. ft.
21.REMARKS
Parcel Identification No.(PIN) �I" .T1.r,�170 1'Cer,
County ••• •� • •'J vtiVvit\J VIr,I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
3G'- fC: 7Z N RO' V6 17 W
L
6.Is(are)the well(s): tKrmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MiV 0 15A NCAC 01C.0100 or 15A NCAC 02C.0100 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 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: ` q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / or, (ft') Submit this GW-1 within 30 days of well completion per the following:
Fos multiple wells list all depths if different(example-3(rr)200'and 2@1001
b 24a. For A11 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
i
If water level is above casing,use"+" / Q
Bit Off: F9 01'r 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Prograrn,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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depailment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA P
11 Permit Program,1611 MSC,Raleigh,NC 27699-1611 1
13a.Yield(gpm) v Method oftest: t^fY
0 DATE SITE VISITED: 7
1
13b.Disinfection type: 70/o HTH Amount: OZ ��6*rt� VISITED BY: � g rc
Pri r�P
-.... — 'r-..r,n.....v.,•n•n„i.—".fP i—mrntat Onality-nivisinn of Water Resources Revised 6-6-2018