GW1-2021-00181_Well Construction - GW1_20211213

WEtL,nCONS'TRUCjTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Inform ntion:
14.WATER ZONES
FROA, TO DESCRIPTION
Well Contractor.Name 1 lt• Q ft.
J�f / a
ft, a&r ft 3,0 i
qC ive11 Contractor Certification Number 15.OUTER CASWG for multi-use wells LINER if a licable p
YADKIN WELL COMPANY,INC. FROM To DIAMETERI THILXNESS MATERIAL
ft ft. I I in.
Company Name 16.INNER CASING OR TUBING eothermal rlosed400 )
2.Well Construction Permit#: FROM T I DIAMETER 1 THICIOVESS MATERIAL
List all oppllcable well constructlon permits(ca WC.County,State,Yarlance,eta.) 411 I tew"•
3.Well'Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well: mom TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
i
❑Industrial/Commercial OResidential,Water Supply(shared) 18.GROUT
`!J`) ❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD✓4 AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.5AND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft, ft.
❑Rxperimental Technology ❑Subsidence Control It
ft
tat'cotliermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardven,soiVrock in size,etc
❑Geothermal(Heating/CoolingRetum) ❑Other(explain(under#21 Remarks) ft , ft. s0 L
�T
4.Date Well(s)Completed: ����1'a well ID# A6 O ". % r1l" erw
5a.Will Location: Phone # 4��- /y�Y G r// S p ft 3� ft (.'r i, ._e ;
O V (O 7
ft ft
mekt
Facility/Owner Name II 1Facility IDN(if applicable) ft. ft
ft ft.
3 2,c)� �h•c
Physical Address,City,and Zip ft fq
21.REMARKS
BORES (Z.) DEPTH (3?j
County; Pascal Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LOOPS PER BORE L ) DIA OF LOOPS
(if well ifeld,one lat/loagis sufficient) 22.Certification: SDR OF LOOPS (Gt )
SG " 63. 9.Ct Ct N 7.P" 7. ©f�' wal2io" � ( 11_/g-J•y
6.Is(are)the well(s): Vermanent or ❑Temporary Sign of CertiAd Well Contactor Date
_ � By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �O 1 SA NCAC 02C.0100 or LiA NCAC 02C.0200 Well Construction Standards and that a copy
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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3.1e s Vt.) Submit this GW-1 within 30 days of well completion per the following: ,
For multiple wells list all depths jdifferent(example-3(a)200'and 2©1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Bit Off: 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction diethod:
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 produciri:g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: •
a DATE SITE VISITED: 7-124'a 1
•13b.Disinfection type: 70/o HTH Amount: OZ
VISITED BY:
a Department of Environmental Quality-Division of Water Resources Revised 6-6-201 g