GW1-2021-00277_Well Construction - GW1_20211213

tC�l�T�11lT�N����IQirC� ➢�13�-�1 For Internal Use Only:
1.Well Contractor Information:
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l/VG.�f.dys 19.WATER ZONES I
--- FROM TO DESCRIPTION
Well Contractor Na�be ft. ft.
fL ft
NC 1eU Contractor CertifieationNumber F ,
IS.Otrm CASING for multi-rased wells ORLINER d a Gcable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNE65 MATERIAL 6 6<
ft it. in.
Company Name
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16.INNERCASINGORTUBING eothernWclosed-loo
2.Wetl Constrdcbon Permit#:
t• FROM TO DTkA TEICIINLss T'IATI.RIAL
List all applicable well construction permits(i e.L11C,County,State,Variance,eta) it in.
3.Well Use(checkwell use): it ft. in.
Water Supply Well- 17.SCREEN
FROM TO DIAMETER SLAT SIZE TEICIOYESS MATERIAL .
❑Agricultural ❑MunicipaUPtiblic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) JZesidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ORcsidential Water Supply(shared) 18.GROUT
❑irrigation OWells>100 000 GPD' FROM TO MATERIAL 1;MP CEMENT n2ETEOD&AMOUNT
Non-Water Supply Well: ff. ft'
OMonitoring ORecavery M ft. --
Injection Well:
ft fL
❑Aquifer Recharge ❑Groundwater Remcdiation
19.SAND/GRAVES.PACK da licable)
❑Aquifer Storage and Recovery ❑Salinity Bawer. Mom ,To I MATERIAL EMPLACEMENT METHOD
- ❑Aquifer Test ❑StnrmwaterDrainage
OBxperimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRIL1INGLOG attach additional sheet ifnecessa
❑Geothermal(Heating/Cooling Retimn) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color Larches:,s°Vroek a sae etc
.PL ft.
4.Date Well(s)Corupleted: I�7 a I `Well ID#
Phone#
5a Well Location:
D /f SeN" ft fc
r
Facility/OwnerNeme Facilitym#(if.gyUrable) ft';' ft
ft.
Physical Address,City.and ft ft.
G�tetl es bba' A�
County Pare]Ideatitication No.(FIN) malt
5b.Latitude lud longitude in degrees/minates/seconds or decimal degrees: .A t>VG'�'�s
(ifwell field;onelat/longis sufficient) 22.Certification:
6.Is(are)thewell(s): permanent or ❑Temporary Sigeatn ofC ed Well Contractor Darn
By signing thisfarm,Thereby certify that the wells)was(were)construi:drnaccordancewtth+
7.is this a repair to an existing well: 7'A or MNo ee�C.e e r 15A NCAC 02C.0100 or l5A NCAC 02C 0200 Well Construction Standardr and that a copyti f,
If thin is a repair,fdl out known well construction information and explain the nat5-of the i is record has been provided/o the it+ell owner
} ✓x S
repair under#21 remarks section or on the back of this form. r t
23.Site diagram or additional°weUuetails:
8.For Geo robe/DPT or Closed-Loa Geothermal Wells Navin the sr�e You may use the back of this page m pi oxide additional well consructon rnfo
construction,only 1 GW-�is needed. Indicate TOTAL NUMBfiR of wells (add'See Over'in Remarks Box).You niay'also attach additional pages if necessary P
drilled:_ 24.SUBM rL4,L INSTRUCTI&S
r 8S ft.
9.Total well depth below land surface: 3 ( ) Submit this GW-1 within 30 days of well completion per the following
For multiple wells list all depths!f diettttt(eramp/e-3(c0200'and 1�100�
ft 24a. For All Wells: Original form to Division of Water Resources (DWR),'
. 10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: s 24b.For Iriiection Wells:Copy'to DWR,Underground injection Cotiti6fi UC)
11.Borehole diameter: (in.) ,•
Program,1636 MSC,Raleigh,NC 27699-1636 s+w t
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells'`bopy to the`,1
(i.e.auger,rnhmy,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d:-for Water Wells produci3�9 over 100,000 GPD:Copy to DWR;,,CCPCUAI% ,`
c PamitProgram,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: ��/� a ems+" "
13b.Disinfection type:- 70%HTH Amount' J^i �O,Z, DATE SITE VISITED:
- - - - TED BY' r