GW1-2021-00273_Well Construction - GW1_20211213

� WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
I �OA `0-V-L 14.WATER ZONES
FROM I TO DESCRIPTION
Well Contractor Name ft, -ft-
Li y
/h
Sfr. ft.
W
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas' wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MSATERIAL
ft. ft in.
Company Name 16.INNER CASING OR TUBING eothermal closed400
//++ IAMETER TEaSS MATERIAL
2.Well Construction Permit#:�� � � 4r FROM TO D
List all applicable well construction permits ri.e.7ffC,County,State,Parlance,etc) ft• 3 C1 ft a X3 'n y c V ,) ee i
ft. ft. I in. I ,
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FRONT TO DIAMETER SLOT SIZE TffiCKNESS MATERUL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 4Residential Water Supply(single) ft. ft. .
❑Industrial/CommercW ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6-ft. ft. a" m )t C ' a S
❑Monitoring ❑Recovery LJ "' g ft (,e,1)T1Ir�L 9 ; ^,og,erg
Injection Well: ft, ft. Fop
❑Aquifer Recharge ❑Groundwater Remediation19.S /GRAVEL PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft'
❑Experimental Technology ❑Subsidence Control. ft ft.
❑Geothermal(Closed Loop) ❑Traces 20.DRILLING LOG attach additional sheets if necessa
` - FROM TO DESCRIPTION color,hardness,soilfrarktyp4 grain sae,etc
❑Geothermal(Heating/Cooling Return) s'I❑Other(explam�undeder#21 Re sm�arks) I .. ® r t ft
4.Date Well(s)Completed -� � .We11ID#llll!"� L� 11 ft �✓`o ft ( legV &V4 �s '�G� f�°q y
iJ
Sa.Well Location: F'f one #�IQ-B'8'®-3��.5, 3u *), p WG1e�
ft
Ra.1ty1lOw.nerNamm- Facility M#(if apphcahlq) ft ft
ft ft.
�,,
ft ft
Physical A s,City,and Zip
21.REMARKS `
County Parcel Identification No.(PIN) 1 3 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one htt/long is sufficient) 22.Certification-
-3
' " 3-W N 0�1 X 34fla W 1-1 6"12 t
6.Is(are)the well(s): permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orl0 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well 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.
repair under#21 remarks section or on the back of this form. 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 n�eded. Indicate TOTAL NUMBER of wells (add'See Over'in Remariz Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf different(example-3@200'and 2@100)
� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: _ (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
if-water level is above casing use"+" J
Bi ®�
t Off: �� 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 WELLS ONLY: 24d.For Water Wells producing over_100,000 GPD: Copy to DWR,CCPCUA
f ^ R Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t Method of test: ,
13b.Disinfection type: Amount: 0
70%HTH ' ® OZ DATE SITE VISITED: ^��'�:Z� �1 v 0,
VISITED-BY:
Pr