GW1-2021-01711_Well Construction - GW1_20210305

L LI 0;:1 TS TAtU TIODI Lai C0—R,7190'('GVV=1) For Internal Use Only: I �C
L Well'Con tiactor Inlorr-�atiow r
e e— 14.TYATER ZONES l k
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� PSP E
Well Contractor Name (i.`� l PROM TO DESC TION
a
7 ` ` ft.
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NC Well Contractor Certification Number �.`'',
�'�" _ 15.OUTER CASIPTG for multi-cased wells)OR LINE if ap licable
YADKIN WELL COMPANY,INC. k,7
FROM TO DL�METER THICKNESS MATERIAL
�'i ft. ft. j in. i I
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Company Name `
�� a a I 16.INNER CASING OR TUBING eothermal closed-ldo
2.Well Construction Permit#: PIP FROM TO DIAMETER :THICKNESS MATERIAL {
List all applicable well constatclion permits(i.e.UIC,Couny,State,Pai lance,etc.) 41
ft. ft. j in.
3.Well Use(check well use): €t, ft. in l/ e
17.SCREEN \
Water SuppiyWell: FROM TO DIAMETER SLOT SIZE TM094ESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. i •
❑Geothemlal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft• i�• r n
❑Industrial/Commercial ❑Residential Water Supply(shared) 15 GROUT v
❑Irrigation ❑Wells>100,000 GPD FROM TO II•IATERIAL EMPLACEMENT METHOD&AMOUNT
Nora-Water Supply We19: 1J ft. ft. 5rat�ta,-1t $ )^�� s
❑Monitoring ❑Recove ft. ft. J c
Injection Well: ry �C.t7�clr�r r � /✓rr rJ e.� e
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 'MATERIAL EMPLACEMENT METHOD '
El Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soilirock e, rain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. s ft. Dl�
4.Date Well(s)Completed: '9 X aj Well ID VA ft. 1 ft.
Sa.Well Location: Phone 41 ft. `) ft. f,e. /
Facili�'r Name� Facility #(if applicable) - C ft.
1 G W 16�rG/ AM I ft.
1
Physical Address,City,and Zip ft. ft.
21.REMARKS
County /I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `
(if well field,one lat/long is sufficient) 22.Certification:
Aee"),�OL ale_
6.Is(are)the well(s)l�rmanent or ❑Temporary Signature of Certified well Contractor ! Date
By signing lhisforni,I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO 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 c
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: 1
24.SUBMITTAL INSTRUCTIONS �
9.Total well depth below land surface: / 69
(ft') Submit this GW-1 within 30 days of well completion per the following:
h7br multiple wells list all depths iil dierent(example-3Q200'and 2@1001 6
24a. For All Wells: Original fohn to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 J
If water level is above casing,use"+" a
11.Borehole diameter: tP, (in.) Bit Off: P•� / 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 Operi-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 producingYover 100,000 GPD:Copy to DWR,CCPCUA
l� Method of test:
G Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)
n DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZ �j 1
VISITED BY: I/f A _ / • `
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources [ Inv Revised 6-6-2018
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