GW1-2021-00180_Well Construction - GW1_20211213

I
WELL CONSTRUCTION RI E CORD (GAY-1) For Internal Use Only: I
1 LWell Contractor Informntion:
i
tt�N mV l,-3 14.WATER ZONES
-��� FROM TO DESCRIPTION
Well Contractor Nadre
.0 R. •ft.
J � O
4 J"R. IL I
NC Well Contractor Certification Number 15.OUTER CASING for multi used 11s OR LINER if a livable
-YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERrAL
Ft R. in.
Company Name 16.INNER CASING OR TUBING fimothermil r]osed-loo
2.Well Construction Permit#: FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(ee.UIC,County,State,Variance,eta) ft (� Rt. J l
3.Well Use(check well use): ft. ft. r in.
17.SCREEN
Water Supply Well:
I7t0At TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercia-I ❑Residential Water Supply(shared) 1B.GROUT
❑Imgation CWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. O ft.
A�
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK if a linable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROIti TO MATERIAL EhIPIACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage R• ft.
X'O
enmental Technology ❑Subsidence Control ftthermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color hardness soillroek ain sce etc
❑Geothermal(Iietlting/CoolingRetum) ❑Other(ex lain under#21 Remarks O : . e
ft. 7s'ft. �J ct'0•L
4.Date Well(s)Completed: 1' Well ID '� g S ft. 4�e•ft.
a. Sa.WtivLacasan: ( Phone# �19- �ir2-0�Zs�i WeR. 8o•ft_ ,
R. ft
Facility/OwnxName Facility M#(if applicable)
A
12-03 L211.dernbj_j f� ate&ka�� ft ft. ft.
Physical Address,City,and Zip -
0 21.REMARKS
��B BORES (2) DEPTH (3 L 1
County. Payee]Identification No.(PIIi)
P 4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE ( ) DIA OF LOOPS
(ifwell;field,ono fat/loagis sufficient) 22.Certification: SDR OF',`,LOOPS (Ge )
o ®S ct ct cl N / U 9-). OUT w
6.Is(are)the well(s): ❑Permanent or ❑Temporary Sign of CerdWWeU Contractor ate
By signing thisform,I hereby certify that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V0 1 SA NCAC 02C.0100 or ISA NCAC 102C.0200 Well Construction Standards and that a copy
If this u a repair,fill out known well construction information and eapIlain the nature of the of this record has been provided to the well owner
repair under 021 remarks section or on the back of this form.
23.5ite 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 Remark Box).',You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: WO, (fn) 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©1001
24a. For All Wells: Original!form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
dfwa(e,level is above casing,use
11.Borehole diameter: G (in.) Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction thethod: 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 WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
t f Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �7 Method of test: �l qq�
70%HTH OZ DATE SITE VISITED: 7�,�p'2.1
13b.Disinfection type: Amount:
VISITED BY: 0"
na Department of Environmental Quality-Division of Water Resources Revised 6-6-2018