GW1-2021-01158_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD (GW-1) For internal Use OnfF___ ._..--
1.Well Contractor Information:
14.Wt17'ER ZONES
Well Contractor tame - FROM TO DESCRI t ION Jk.
NC Well Contractor Certification Number 15.OUTER CAS
IRIO(for molt[-creed e$ells)OR LiNER(if a licatile
YADKIN WELL COMPANY,INC. r, ; ' FROM TO DIAMETEP, TE1cKNEss IviniCRL1L
ft. it. in.
Company Name �y �n 16.INNER CASING OR TUBING'(Neotherii a]closed-loop)
2.Well Construction Permit#: P9W1_ P-Odoo 3370 FROM TO I Dulw]ETER THICKNESS MATERI)�L
List all applicable well constuction permits(i.e.UIC,County,State,l/arionce,etc) ft. oeft. ! in.
3.Well Use(check well use): ft' ' in.
Water Supply Well: 17.SCREEN
FROM TO l UTAME T R SLOT SIZE THICKNESS MA T EDUAi. _
❑Agricultural ❑Municipal/Public ft. ft, in. -�
❑Geothemlal(Heating/Cooling Supply) iential Water Supply(single) ft ft in.
❑Industrial/Commercial RkVsidential Water Supply(shared) tS GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO R'1ATEr<IAL EnIPLACEhirENTR-rETx®Ia�.:ttiOziNT
Non-Water Supply Well: ® ft. ' R. !�- o v w-ed
❑Monitoring ❑Recovery ' ft. ' ft.
Injection Well: 3 ��
fft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAi+iD/GIAA'EI PACK(ia, '.Icdrtle)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO NATEM L ERtPLACEMENTNIETIIOP�--
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.:DRILLING LOG(attach additional sheets if necessary)
FROIs•I TO DESCMPTION(color,hardness,soil/roch ty e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: �"'! Well ID# fft. ft.
ft. ft.
5a.Well Location: Phone #.
AetvldH c.fei�'r ft. ft.
Facility/Owne Name Facility ID#(if applicable) fft. fft.
ft. ft.
Physical Address,City,and Zip ft. ft.
21.RE TVIARKS
County Parcel Identification No.(PIN) �``5 `n Well aYJ gb�/GOl�1oC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1�tf M C1 roV
(if well field,one hit/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s): ❑Permanent or ❑Temporary SSW,-of CedXed Well Contractor Date
By signing thisform,1 hereby+certi6,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: As or 19No 15A NCAC 02C.0100 or 15A NCAC IO2C.0200 FVell Construction Standards and thal a copy
If this is a repair,full out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section at-on the back of thisform. 1
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 necessa
drilled:
1 � 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �ir7 [ 'nte+ (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 t©200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7r 3 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iftvater level is above casing,use
11.Borehole diameter: (in.) Bit Off: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: G
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
l
VISITED BY: f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201
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