GW1-2021-00300_Well Construction - GW1_20211213

{ +CONS R UCTIO�t RE�C d��-�1 For Internal Use Only:
7s';l:Well Contractor Information:
�r[y l/ya�rk s 14.WATER ZONES
F TO IPTION
f WellConhactorName FROM t DESCR
ft.
NC Well Contractor Certification Numbs
15.OUTER CASING for multi-rased wells ORLINF R if a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TlmczavEss MATERIAL
in.
Company Name 16.INNER CASING OR TU13ING 6ieathermalelosed-loo
2.WeU Construction Permit#: v,^`.LA°p�rr- O Q-4 6 /y-10'1` FROM 7TO I DIAMMTER LTmcrams I mATERiAL
List a!/applicable well constiuction permits(ce UIC,County,Slate,Variance,etc) 14, 11 1 er in. SDR 2% I Pvc
3.Well Use(checkwell u e) ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE IMCKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ($Residential Water Supply(single)
ft. ft. in.
❑Industdal/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT NIETHOD&AMOUNT
Non-Water Supply Well: 0 ft• 3 Role` Pl Povrol-
❑MonitorW ❑Recovery 3 ft a7 ft' anck. �t Pv •J 3 ba
Injection Well: ft ft❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK rfa Urable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stortnwater Drainage ft. I ft. '
❑Experimental Technology ❑Subsidence Control R I ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necev58
❑Geothermal(Heating/Cooling Rehnn) ❑Other(explain under#21 Remarks) FROM I TO DFSCMIP77ON color,hardneas,:os/roektype,gmm sae,etc
O rt L)0 ft. 50'i
4.Date Wells)Completed: la 3 I a t well D# 'Y Yo ft. 3a3 ft
. .u,� ®fit �A Jr
5a Well Location:
� /'� PhOne t1.7 �'�Og�✓�� � ft
fL
Facility/Owner Name Facility M4(if applicable.) ft
f S u; ry ft' f�EC
Physical Address,City,and Zip & ft
dp� f
1e� 21.REMARKS
County Parcel Identification No..(Fo
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees.
(ifwell field,one lat/iongis sufficient) �� �� 22.Certification:
N 00" iC . W I a 31.71
6.Is(are)the well(s): aermanent or ❑Temporary Signatur of C ed Well Contractor Date
QC&we,,g By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or � a 0 15ANCAC 02C.0100 or iSANCAC OjC f0200 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 retard has been provided to the well owner. \
repair under{t21 remark section or on the back ofthis 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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: f24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J a:) (ft.)
For multiple wells list all depths ifdifferent(example-3(n)200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
NO ) 24a. For All Wells: Original fo m to Division of Water Resources (DWR),
If
f Static water level below top of casing: (ft) Information Processing Unit, MSC,Raleigh,water level Is above casing,use"+" �+ i NC 27699-1617
11.Borehole diameter: (�) Bit Off: �7• S 24b.For Tniection Wells: Copy to DWR,Underground Injection Control(TUC)?"
Program,1636 MSC,Raleigh,NC 27699-1636 z=..
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open!Loop Geothermal Return Wells Copy to the.
(Le,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) lr0 Method of test• n Perlluut Program,1611 MSC,Raleigh,NC 27699-1611
® c /A
70%HTH ' DATE `— g— �
136.Disinfection type: Amount: OZ E SITE VISITED:_ w
VISITED BY: � �