GW1-2021-00196_Well Construction - GW1_20211213

I . S UCTIOON tldhE COO D (GW-1) For Internal Use Only:
1.Well Contractor Information: `
_ _may ch,s to u L t� 14.WATER ZONES
Well Contractor Name t1 FROM TO DIISCIiIYTION
ft /%fft. J%Z gr`
NC Well Co o7 �q�ectificatio Number
15.OUTER CAS G formulti-r�s6dvYeAs LWFR tfa licahle
YADKIN WELL COMPANY,INC. FROM To DIAMETER Ts�tznvEss MATERIAL
ft. ft. in.
Company Name s vet 3 - G*)a t -�
g 99 16.Il�II�TER CASING OR TUBING eathrrmal closed-loop)
2.Well Consf u'cdon Permit#: Z E - —&P, rC " 0 FROM To DIAhn.TER TMCIiNi':SS I%O ATMUAL
List all applicable well construction permits(i e.EIC,County,Slate,Variance,etc.) ft ft ➢'
3.Well Use(eheckwell use): ft ft. in.
Water Supply Well: 17,SCREEN
PP y PROni TO MAW=R SLOT SIZE THlaa4uss MATERIAL
❑Agricultural ❑Munieipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply)" 4sidential Water Supply(single) ft. ft. in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD PROM To MATERtAI. EMPLACEMIiNT METHOD&AMOUNT
Non Water Supply Well: ft. ft
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SANID/GRAVES.PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLiCEMLNT ivtB'rsoD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/CoolingRetum) ❑other(explain tfnder#21Remarks) FROM TO DESCR=ON calar,bardnrm,s0ratktypr,paj.simctr-
A.bate Well(s)Completed: �-� Well ID#
; � 36 ft ft
5a.Well Location: Phone # 7n V- V- ft ft
�V ft ft !;
ft. ft 'Ile
Farn7ity/Owner Name FacilityIIl(l(ifappffeable) ti
ft. ft
v f{ tI
Physical Address,City,and lip ft ft
21.R.HMAR%S
Comity Parcel Identification No.aM4) ' gpsK / ®w
5b.Latitude and longitude'in;degrees/minutes/seconds or decimal degrees:
(Swell field,one lat/longis snfficieut) Q 22.Certification: U
6.Is(are)the well(s): 4rmanent or ❑Tempor Si a of Ce d We Contracror Date
PP`s O e�ee By signing thlsform,I hereby certify that the well(k)was(were)constructed in accordance with
7.Is this a repair to an e:dsting well Yes or o 15ANCAC 02C.0100 or ISA NCAC'02C.0200!Yell Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
re
pairunder#21 remarkrsection or on the back ofihis form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or CIosed-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 Remmk Box).You may also attach additional pages Ynecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3a� (ft.) Submit this GYV-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdi#erent(example-3@200'and 2@100D
e t .0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7 d (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing.use"+°
f Borehole diameter (in.) Bit Off: ,�,9 7.2., 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. 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
(La.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLYWELLS'ONLY: 24d.For Water Wells prodacin(g over 100,000 GPD:Copy to DWR,CCPCUA
4�-A)4V Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: O' y-
o '9 DATE SITE VISITED:-9-1L e�� ®47
13b.Disinfection type: 701a HTH Amount: / OZ i
- VISITED FAY—