GW1-2021-00124_Well Construction - GW1_20211109

WELL CONS 1 'UCTI+( N RECORD (GH-1) For Internal Use Only:
1.Well C ntractor I ormstion:
//
J`7 �ilN P[� li✓l'1 14.WATER ZONES P
Well Contractor Name
FROM TO DB.SCRIPTION
"', :Ilk } �►e,
3®3 6.� D
d J
NC Well Contractor Certification Number 7� ft 3 ft 1!y
i 15.OUTER CASING for multi-rased wills ORLINER rf a Geable
YADKIN WELL COMPANY,INC. t FROM T DIAMETER TffiC7QIESS MATERIAL
ft m.
Company Name /� 16.INNER CASING OR TUBING g eothutiud elosed4no
2.Well Construction Permit#: 6 6 2� FROM TO DvNXrER I TMc1G rss I mATERIAL
List all applicable well construction permfis(Le.DIC,County,State,Parlance,et¢) fL off R 6,21 in. 0,lMv up AV SAee
fL
3.Well Use(checkwell use): fi' 1°" ly �(, J•
Water Supply Well: 17.SCREEN
FROM TO❑ DIAA'iHrER SLOT SIZE THIC[QYESS MATERIAL
❑Agricultural Municipal/Pubiic ft ft. in.
❑Geothermal(Heating/Cooling Supply) fesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT -
01n igation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT ATETHOD&AMOUNT
Non-Water Supply Well: d ft. 3 R
❑Monitoring ❑Recovery R a ft P v
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft 8
❑ r Storage and Recovery ❑$ Barrier 19.SAND/GRAVEL PACK(if a licable
Aqulfe rage erY ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑SImmwater Drainage R-
❑Experimental Technology ❑Subsidence Control ft it . 01
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM I TO DUCRIMOx color,hardness,soMmektypr,gnin sire,cte.
�
4.Date Wells)Completed: /� t` © Well ID#Aw y l "L 70 ft ...r
ssC,v
Sa.Well Location: �✓ Phone # 33(#-g5 0j4; 70 g/o,�, ft r
AQm tU/s V 0 tf ft ft C
ft ft. b
Facility/OwnerNamE' Facility ID#(if applicablgj/���
Ile fL NOV
Physical Address, ' ,and Zip '
&A
county ParcelIdentifiostionNo. v / �Av
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/loagis sufficient) 22.Certification:
—34 bra-&5T N 01 lGj, '' _
6.Is(are)the well(s): pbermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or Mo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
ythis 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.
repgir tinder#21 remorkrsecitan or on the back ofthisform. 23.Site diagram or additional well details:
S.-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. UM Indicate TOTAL NUMBER of wells (add'See Over'in Remado Box).,You may also attach additional pages if necessary.
drilled: ! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) j
For multiple wells list all depths Ifdifferent(erample-3 a0200'and 2Q1001 Submit this GW-1 within 30 days of well completion per the following: _
0 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),J
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaier level is above casing useCK
11.Borehole diameter: fD (in,) Bit Off: . 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Op en-Loop Geothermal Return Wells•Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells yroducida over 101000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit rogmn,1611 MSC,Raleigh,NC 27699-1611
', � Q L`
70%HTH __ OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
- VISITFn RY• a /