GW1-2021-00293_Well Construction - GW1_20211213

STRT1CT ON RECORD (GW-1) For Internal Use Only: f
1.Well Contractor Information:
14.1'VATER ZONES
Well ContractD ame FROM TO DESCRIPTION .,A 1
ft ft. J{ I O {
ft �I
. ft v I
NC Well Contractor Ccrtification Number 15.OUTER CASING for multi-rased wells ORLINFR if Gcable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TffiCENESS MATERIAL
ft ft.
Company Name YOA�et� 2�e��� 16.INNER CASING OR TUBING eot}rumal dosed-:loop)
2.Well Construction Permit#: 4t/3 M E -0 12 2 35 'A OZ FROM TO DIAMETER TffiCIGiESS MATMUAL C�
I List all applicable well construction permits(Le.UIC,County,State,Trariance,etc) It
p ft .0'Ir in. w„ vG e'er
3.Well Use(checkwell use): / ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TMCKN'KSS MATERIAL,
I7Agricultural r11i'd*ential
icipal/Public ft. ft, In.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) .
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
DIrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMErNThIETSOD&AMOUNT
Non-Water Supply Well: ". ' It as eVr%
❑Monitoring ❑Recovery ft y•ft ��I�
Injection Well:
ft fL
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK Of amilicable)
❑A.quifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPIACEMENTR=- OD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothenmal(Closed Loop) ❑Tracer 20.DRTLL7NG LOG attach additional sheets if necessary)
❑Geothermal(Heaiing/Cooling Rehun) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiurork • :im,ctr-
AA,�, [�• O 'ft Ja L
4.Date Well(s)Completed: 2'�'r�_Well ID#/='ti". 3� S � 1.)'R 40' / -%Rp
5'a.D Well Location: /PhPne �(����®c���Z fL ft
fu/LCA U W.1 -To ft ft
Facility/OwnerName Facility IDA(if applicable) ft ft
37 -33 l,.�w ft. ft 3 202�
Phyaieal Adds,City,and Zip ft ft
KIN rt, 21.REMARKS
County Parcel Identification No.(PIN)
s
5b.Latitude and longitude in degrees/nvnutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
•
6.Is(are)the well(s): 9 ermauent or ❑Temporary re of C ed Well Cofactor Date
-1 C
By signing thisfarm,I hereby certify that the well(s)was(were)constructed in accordonce with
7.Is this a repair to an eidsting well: ❑Yes or ijo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
$this is a repalr,fill out brown well construction b7formation 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 additionalwell 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 im1b
construction,only 10 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'inRemarics 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 da s of well completion the following:
For multiple wells list all depths If XffirenI( per example-3@200'and 2®100� y, p p g•
Swf� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
if water level Is above casing,use
11.Borehole diameter: �iv+ (in.) Bit Off' •0 b3 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 Opei-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
1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 266. Method of test: �
70%HTH - 9 OZ DATE SITE VISITED: �
13b.Disinfection type: Amount: `F
VLSITFr)RY•