GW1-2021-00268_Well Construction - GW1_20211213

/ RECORD+L L,Cp�NST NCTI+©l�t �V� -1) For Internal Use Only:
L Well Contractor Inforrantion:
Q. L 14.WATER PANES
FROM TO I DESCRIPTION
Well Contractor Name
[� rt. 151
ft. o
NC Well Contractor Certification Number 15.OUTER CASING for rdulfi-cased wells ORLINER if a licable
YADKIN WELL COMPANY,INC. FROM��� T� � D 1 O �. �S� G�� ���
Company Name
^� �g�r r 16.INNER CASING OR TUBING(geothermal closed-lac
2.Well Construction Permit##: 7 5 FROM TO DIAMETER TIticia mss 1 MATIIRUIL i —
List all applicable well construction permits fl e.EIC,County,Slate,Variance,eta) 4. ft ft m S O 21 PVC
3.Well Use(check well use): ft ft. m. tag
Water Su 17.SCREEN G
PPIy Well: I1tOM TO DIAMETER SLOT SIZE THICNXESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) AGsidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT R
Nan-Water Supply Well: 0 ft. 3 ft 16- ,t' -f tC��� ' � 4J k-&( .�}►J�
❑Monitoring ❑Recovery 3 ft ft- s n d r.
Injection Well:
ft. ft. S
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVELPACK da livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. 5,r LACEMENTME=oD
❑Aquifer Test ❑Stormwater Drainage ft-
❑Experimental Technology ❑Subsidence Control it it.
❑Geothermal(ClosedLoop) ❑Tracer 20,DRILLING L0..G attach additional sheets if necessa
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM!ft
TO DESCRIPTION(color,h.,ntne�s,miumetc a to sae etc
V ft. AM
4.Date Well(s)Completed: (�� ' Well " 1 t� f �VI ct d
5a.Well Location-
Phone # 3j�� � �!j3 7 a / ft ' u 1c, G� ,V�
� K fin 1A d1
Facility/OwnerName Facility ID#(i�f applica�bl{e/) � 5ft /tad mac/
zz t�/���/�� tvV��l�!'(� �e�K7h IVU t�j ft 4!"4- , e'uW S. -,t
Physical Address,City,and Zip + ;6 ft ♦� if. M Y
r
21 REMARKSe
Copy Parcel Identification No.(FIN)
r.
5b.Latitude.and longitude in degrees/minutes/seconds or decimal degrees: '
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): Aerinanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AND 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
If this is o repair,fill out lmown well construction information and explain the nature of the of this record has been pravided to the well owner.
repair under#21 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 OW-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: (ft')
For multiple wells list all depths Ifdifferent(example-3@200'and2@1001
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 'T (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing use"+"
11.Borehole diameter (p (in,) Bit Off: .a 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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 WALLS ONLY: 24d.For Water Wells producin�over 100,000 GPD:Copy to DWR,CCPCUA S
Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test: �I(r-
70%HTH OZ DATE SITE VISITED: a-
13b.Disinfection type: Amount: 17
VISITED BY: 1/9