GW1-2021-02702_Well Construction - GW1_20210809

' CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1 Well Contractor Information: ^ fi
_ J`p C.IQ l� d "f° 14.WATERZ0NLS i C
FROM TO HESCRIPTION'"
Well Contractor Nal.
G
NC Well Contractor Certification Number taw SOO�r�5'o RRIOUTER CTOSING,foF m"uD AMETERelli'ORLINE ,(if a Itbli)_'MATERIAL /YADKIN'WELL COMPANY,INC. 5' 6\ er
_ ft. ft. in.
Company Name '�tr�.�'� 3 y�(t'e� ��t� � � ,r,
\ 16.INNER CASING OR,TUBING. eothefmal closed-loo
2.Well Construction Permit#: � L FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) ft. 43 ft. 9,in.
3.Well Use(check well use): ft. ft. in. 1�
Water Supply Well: 17.:SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�/Municipal/Public ' ft. in. G
❑Geothermal(Heating/Cooling Supply) &'Residential Water Supply(single) ft. ft. in. Ifi
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.'GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 'ft. Fn.0
❑Monitoring ❑Recovery [- ft. 3y'ft. 66H��0I Oval
Injection Well: . ft. ft. 9
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEUPAC& tfa' hcnble '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.,DRIL"LING>LOG :it6'6h ddditioniilstieetsif.necessa"
FROM TO DESCRIPTION color,hardness,soiUrodc _type,• rain sic,etc.)
❑Geothermal(Heating/CooGng/Return) ❑Other(explain under#21 Remarks) ft. ft. - C
4.Date Well(s)Completed: Well ID#AAAo- I- $ ft. 32d ft. f�s® /V sb e:�r r
5a.W�ell Location: /� ^
- Phone # y,%-S1 �9. ,3 g 7I 3;L0 ft. .y0 ft. x)( cQ sa T�
Or. Z pe-1 d'T�^�i-r w !]�t\a m arx 517 ft. v r® ft. �C feu s„70 T
Facility/Owner Name T- Facility M#(if applicable) �® ft. `/173 ft.
�l y l�L�. F��✓Y 2d /7.j ft. ft VF ft. S
Physical Address,City,and Zip Me ft- (J-q3 ft.
21.REM:ARICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal,degrees: ev r O
(if well field,one lat(loXT
t) 4 0
22.Certification:
N RO- 2-6
6.Is(are)the well(s): permanent or ❑Temporary St of Cert' d Well Contractor Date
/ By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill 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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r f� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: sJ 7� (ft) Submit this GW-1 within 30 da s of well completion per the following:
ror multiple wells list all depths if dfferent(example-3 00'and 2©100� Y P P g:
10.Static water level below top of casing: L+ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" lnfOrmation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: �''`J� , 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh;NC 27699-1636 t tNV
12.Well construction method: AIR ROTARY
24c.For Water Supply a0dOpen-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
�� Petmit Program,1611 MSC,Raleigh,NC 27699-1611 CA I(6
13a.Yield(gpm) / Method of tes : I h o f•.(W_ 4.1 3
e: 70/o HTH Amount: OZ
13b. c
a DATE SITE VISITED:/-, -2/
9i p.i
tYP G ��•n.i� 2��l
MWVISITED BY: t
Form _ „` North Carol ronmental Quality^Division outer Refources Revised 6-6-2013