GW1-2021-00127_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
d i 0 k.% 14.WATER ZONES
Well Contractor ame FROM TO DESCRIPTION
7 ft • fr.
7��� I
i
NC Wellft. '' ft Contractor Certification Number 15.OUTER CASING for multi-cos ells OR LINER tf a ticable
YADKIN WELL COMPANY,INC. FROM To DIAME R TMCKNMSS MATERIAL f
A� C fr. ft. in.
Company Name KJ)40, V6' •��g' T®'r
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: 6f 6v i'./s-e9(3 2. 2a FROM TO DLIMEnR THICICOSS I MATMRiAL
List all applicable well construction permits ri.e.07C,County,Slate,Variance,etc) fr. *7 ft rn C/►
3.Well Use(check well use): fr' fr'
Water Supply Well: 17.SCREEN
/ FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERAL
1X6cultural •❑/MMunicipal/Public tt. fr. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. io!
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Inlgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ft. �. �. 1
❑Monitoring ❑Recovery ft. ,y• ft.
Ael
Injection Well: ~ems u
fr. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACMMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft fr
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soivrork a ain size,eft
/1^ O & 6 ' - s®sL
4.Date Well(s)Completed: 0• E J"I' Well ID#AAA -�� &y ft. ro>@fL 1we .f Of�� �j �D/Iv� heW
5a.Well Location: Phon t ft f
-n a �Jze Y`�Sqv<e Or 1
ft. ft
Facility/Owner Name Facility 1D#(if applicable) ft. ft. =\
ft
^S'vc .t r✓i .�1 ft
Physical Address City,and Zip fr.
/tf��Ir¢\ k'� 21.RtEMARKS t
<�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one latllong is sufficient) 22.Certification•
3 2-71' N k0® V 7 FPC W /t7Lt8-ia� j`'
6.Is(are)the well(s): VPermanent or ❑Temporary Si a of ed Will Contractor Date
By signing this form,1 hereby cent fy that the we/l(s)was(were)constructed in accordance with ` `
7.Is this a repair to an existing well: ❑Yes or 04o 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
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 thisform.
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: l Z4.SUBMITTAL INSTRUCTIONS 0
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths!f different(example-3©200'and 2©100D
LS (ft.)I 24a. For All Wells: Original 'form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter; (in.) Bit Off: s.��� 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 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 WELTS ONLY: 24d.For Water Wells producil g over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ISrt' ( S'C.A.Si•nj
13b.Disinfection type: 70%HTH Amount: f 9 OZ DATE SITE VISITED:_ L
VISITED BY: Ugh
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