GW1-2021-00125_Well Construction - GW1_20211109

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i -W—�,7,CQj�'S'Ij'}T�UC JT1TQN 1REICQ��GW-1� For Internal Use Only: j
1.Well Contractor Information: j
(A-)CL-Ill­ 14.WATER ZONES I
Well Contractor Name FROM TO DRSCRIPTION
i I r.x'.
a LA 5 a-A ft. s/s ft I 19/11
NC Well Contractor CmtificationN—ber 15,OUTER CASING forniulti-rased weEs ORLINER 0fop licable
YADKIN WELL COMPANY,INC. FROM I To I DIAMETER I Tffic xms MATERIAL
ft, ft. 1 1 in.
Company Name l� 16.INNER CASING OR TUBING eothermal closed-loo
2.well Construction Permit#: / / v— FROM TO DIAMETER THICENESS MATERIAL
� - 530
Liss all applicable well construction permits '.e.LUC,County,Stale Variance etc) �,1 it /!� �n Sv Q 9I P�/C
3.Well Use(checkwell use): ft ft. in.
Water Su Well: 17.SCREEN
PPI3' FROM TO DIAMETER SLOT SIZE TTDCluass MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. r
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL. EMYLACEMENT METHOD&AMOUNT
Non Water Supply Well: Q ft. S' ft -61C Pt V ov c ec) 4 bac S
❑Monitoring ❑Recovery r ft ft. epne1e �, cQ
Injection Well: ft ft •J'
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK i livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stomiwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loup) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessayyl
❑Geothermal(Heating/Cooling Retmn) ❑Other(explain under#21 Remark's) FROM To DESCAIPTTON color,hardness,roigrock sta,etc. s
.dft
4.Date Well(s)Completed: 1 f �� Well ID# /�+� (�� ft '7a� ft fC3A ft
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5a.Well Location: Phone #��a+t:-31�8•,ilr'2- ft
Lee htkcr ft ft
Facrlity/Ovmerl4i& Facility]D#(lfapplicable) t ft
to lc f1 arf � r—,1eA --Bkc
Physical Address.City. ft ft N 0 V 9
21.RBAIARTCS
Co
,may Parcel Identification No.(PIld)
5b.Latitude and to gitude in degrees/minutes/seconds or decimal degrees:
(ifwelllffield,one lat/longis mfficient) 22.Certification:
3fr 1-2` 1 9ff N rl4if. -ft:FC W
6.Ls(are)the well(s): *ermanent or ❑Temporary Signature f Certifi d Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)conntr din aecorr6ce wiih:a`
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy'.
1f this is a repair,fd!out known well construction Information and explain the nature of the of this record has been provided to the well owner
repair under#21 remarla 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 ccnstrucfiori info
construction,only 1 OW-1 is needgd Indicate TOTAL NUMBER of wells (add'See Over in Remarla Box).You may also attach additional pages if necessary.
drilled: d 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths lfdifbrent(example-3@200`and2®100) Submit this GW-1 within 30 days of well completioD per the following: (�
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: '7 00 (ft-) mo tion Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifw6fir level is above casing,use
11:Borehole diameter: (�) Bit Off: G 24b.For Icti njeon Wells: Copy to DWR,Underground Injection Control(WQ
t Prograrn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Oplen-Loop Geothermal Return Wells:Copy to the -
(i.e.auger,rotary,cable,direct push,eta.) county environmental health depWment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciI g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test: 4T Ar
136.Disinfection 70%HTH Amount Sv OZ DATE SITE VISITED:
_.-- -- V
Dry
VISITED 8Y: