GW1-2021-00118_Well Construction - GW1_20211109

+C6N8 0N-RE0DRD (GVV-1) For Internal Use Only:
1.Well Contractor informntion:
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1 t/� L e�V' 14.WATETsZONES
PROM TO DESCRIPTION
Well Contractor Name
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THLCIINESS MATERIAL
ft. ft. in.
Company Name /� 16.INNER CASING OR TUBING eothermal closefl-loo )
2.Well Construction Permit#: //� FROM To DIAMETER TffiCI 5 MATMMU
List all applicable well construction permi s(4e. C,County,Slate,Variance,etc) fr. ft. in. ,
3.Well Use(checkwell use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIOM,SS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/CoolingSupply) �esidentia]Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD, FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r ft. ft.
❑Monitoring ❑Recovery tt ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if 2Rplicablo
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geotheiuial.(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock is sae,ete
4.Date Wells)Completed: Well IDA Zf ,6 J d 130 ft- Q.a ft' ed
5a.WellLocation: Phone # 36r � i � ft
Facility/Owner Name Facility MA(if applicable) ft• ft.
o s �- Rd. • 3-Faq-�� - ft ft
Physical Address,City,and Zip ft.- ft'
$.� 1.REMARKS
r K d
County Parcel Identification No.(PIN) QA i iTl 04
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one lat/longis sufficient) 22.Certification' )
0 O N p ! L 6 J W /
r
Signature of Certified Well Contractor I Date I 1.
6.Is(are)the'well Permanent or ❑Temporary �
By signing thisform,I hereby certify that the we/l(s)was(were)constructed to accordance with
7.Is this a repair to an ccisting well: f es or PJNo�e e-/tv 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constru,Q��o, land c shot a copy
If this is a repair,fill out known well construction information and explain the Xre of the of this record has been provided to the well owner. 1 j
repair under 421 remarks section or on the back of thisform. 23.Site diagram or additional well details:
gT U�d;;;::i� . .
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide=idditionall wF'P, ,js 1 tion 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
9.Total well depth below land surface: 6) (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2@100D
'JC 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �7 (ft') formation Processing Unit,1617IMSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+" / Q
f Borehole diameter: IO (in) Bit Off: �p 1 24b.For Injection Wells:Copy to DWR,Underground Tnjection Control(lUQ
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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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: �
13b.Disinfection type: 70%HTH Amount: t OZ DATE SITE VISITED: G '�
-- - -- -n ®WSITED BY: JZ6
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