GW1-2021-00298_Well Construction - GW1_20211213

TELL CONSTRUCTION RECORD(G21-i1) For Internal Use Only:
I.Well Contractor Information:
yV ()W}� 19,WATER ZONE
FROM TO DESCRIPTION
Well Contractor Name aZ I V ft a I I ft
u 3 (aA gypft. 70 ft.
NC Well Contactor Certification Number
IS.OUTER CASING(forx'ulfi-cased wells ORLINER tf a livable
YADKIN WELL COMPANY,INC. FROM O DIAMETER THICKNESS MATERIAL
ft. ft.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: `IJJ tM F P U'��t is-aom FROM To DrkAmrrrn TMmaMS MATERIAL.
List all applicable well construction permits(ee.UIC,County,State,Variance,etc) ft 6$ ft G 1! in —Al PVC
3.Well Use(checkwell use): ft ft' in.
Water Supply Well: 17.SCREEN
FROM T DIAMETER SLOT SIZE THICMESS MATERIAL
l7Agricultural ❑MunicipaUPublic ft, ft,
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) t.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO AATERIAL EMPLACEMENT AMTHOD&AMOUNT
Non-Water Supply Weli: ft. ft. 91164A " 'tV
❑Monitoring ❑Recovery 3 ft. 1 ft. 61 3
Injection Well:
ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/ PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier MoM TO MATERIAL EMPLACEMLNT DMHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control L ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCRIMON color,hardness,sovrnek is shv,eta
l O ft 6v ft.
4.Date Well(s)Completed: 1�Ls Well m# 4410— & ft ^3 ft 6 r
ft
sa.WeULoeation: Phone #33_ 6-�$�8—SYS ft. t
ft
fL
Facility/Owner ame Facility ID#(if app&able) ft. ft
fL ft
Physical Address,City,and Zip ft ft
vAd" 21.RAM EgIS
Co un Parcel Identification No.(PIN) #4
Sb.Latitude and longitude in degreestininutes/seconds or decimal degrees:
r -710t4fta
(ifwell field,one lat/longis sufficient) 22.Certification:
N �CCz �—j1 r�' W /Xiz;�
6.Is(are)the well(s): igrermanent or ❑Temporary ignature of Certified Well Contractor Data
By signing thisform,I hereby cert ify that the we11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Lo 15A NCAC 01C.0100 or l5A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,Jdl out(Drown well construction information wfderplain 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.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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:, 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lam 3 , (ft) Submit this GW-1 within 30 days of well completion the followin
For multiple wells Ifst all depths!f different(example-3@200'and 2@1000 Y P P er g
10.Static water level below top of casing:
-S"® 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
If water level is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in) Ba Off: '�Z 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 WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /Oz Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
f,�f fi
13b.Disinfection type: 70%HTH Amount: 3 6 OZ DATE SITE VISITED`:
Uri rrA- � � 41dy% �t�g' VISITED 13