GW1-2021-00247_Well Construction - GW1_20211213

For Internal Use Only: 1
1.Well Contractor Information:
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a T-¢h4� �rc)w y^ 14.WATER ZONES
--I FROM TO DESCRIPTION
Well Contractor Name M
3 0 3 , ft j 3 7 fr. Z o ,A i y- ! '.r (o if
NC Well Contractor Certification Number 15.OUTER CASING(for aiulti-cased wells OR LINER if,a''licable
YADKIN WELL COMPANY,INC. FROM TO R;in. THICRNES MATERIAL
fit
Company Name ftAt(ei• 1.�v9 9 So 3^�'�/�• I coo 16.Il�1NER CAM OR TUBING eother closed-l00
2.Well Construction Permit#: j 00 j,2 9 2 OUSCREEN
To DLIMLTER TffiCIINFSS MATEHiAL ^
List all applicable well construction petrttlls(ee U1C,County,State,Variance,eta) ` fit tn. O Z � , / (\
s
3.Well Use(check well use): ft. JtiC Sh
Water Supply Well:pp O I DIAMETER SLOT SIZE TMCIQaSS . I MATERIAL Q
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) �Zft- ;n:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT :: k A�
bOrrigation 0Wells>100,000GPD FROM TO _MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it 3 ft. 'bqi'!� �+•t�' r --�"
❑Monitoring ❑Recovery ft.; ft.
Injection Well: � fit ft.•Bf�,TovT ��.�� viy,'
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK d a linable
❑Aquifer Storage and Recovery ❑Salinity Barrier .FROM TO MATERIAL EMPLACENIENTMETHOD
❑Aquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach add3ho6l sheets if ere ssa ` iw
FROM TO DESCRIPTION valor,'hardness,sa!lt&ek in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. S, K
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4.Date Well(s)Completed: 1 aJ�f well ID#f�'�® 7S�_ $'� fit i; .kJ �an+-�
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Phone # �0�� 7 ,zj
L. Sa.Well Location:
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4 1 0' fit. 312 ft
Facility/Owner Name Facility M#(if applicable) fit ft.
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ft t` a
�� Physical Address,City,and Zip
21.REMARKS i; x` rE1"
county k to Parcel Identification No.(PIN)
' 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ; V
`L. (if well field,one lat/long is sufficient) 22.Certification:
,jS" 22. 84rC N 85'. S"2. 9O3 w g-al
6.Is(are)the well(s): 0�'Pe
�rmanent or ❑Temporary Signature of Certified Well Contractor Date
By signingthisform,Thereby cero that,the well(j)was(were)coestructed'n accordance with
7.Is this a repair to an existing well: ❑Yes a or o
15ANCAC 02C:0100 or I5ANCAC 02C.0200 Well Construction Standards and that a copy
this is a repair,fill out known well construction information and explain the nature of the of this record has beery provided to the well owner.
If
repair under#21 remarks section or on the back of thisfariv. 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 CA
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remadts Box).You may also attach adonal pages if necessary.
drilled: 24.SUBM=AL`INSTRU
! CTIONS
9.Total well depth below land surfacer O (ft) Submit this Gw-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001
o2V . 24a..For All Wells: Original.form to Division of;Water Resources (DWR),
10.Static water level below top o gsing: (fit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+ /s�,4/s�
Bit Off: 6,206, 24b.For Iaiection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) program,1636 MSC,Raleigh,NG27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 106,000 GPD:Copy to DWR,CCPCUA
0 Permit Program,1611 MSC Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: / Y A/ l` �' kA
o DATE SITE VISITED. l' V ��
13b.Disinfection type: 70/o HTH Amount: 2'1 OZ `
VISITED BY:
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