GW1-2021-01618_Well Construction - GW1_20210305

-WML CONSTRUCTION RECORD (GW-1) of fl Use OnIV:
1.Well Contractor Information:
10-1
an AC WATER ZONES
-4
TO I DESCRIPTION i
Well Contractor Name t, FROM
<
ft.
NC Well Contractor Certification Number
'L ,Il,,lp licable)
YADKIN WELL COMPANY,INC. FROM To "'M " R,T TUMMA-i-ERIAL
Company Name J,_.x ft. ft. in.
; J.J-%,fJ
16.INNER CASING OR TUBING igeotherT L )
2.Well Construction Permit FROM I TO DIAMETER TCHLOI= MATERIAL
List all applicable well construction permits(i.e,UIC,County,Slate,Variance,etc.) + &0A 9( P V(-
3.Well Use(check well use): in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETEM' 3UiTSIZE TORCICNESS NLATERgAi-
CiAgricultural OMunicipal/Public ft. fi.
DGeothermal(Heating/Cooling Supply) desidential Water Supply(single)
In.
01ndustrial/Commercial DResidential Water Supply(shared) -
18.GROUT
DIrrigation E]Wells>100,000 GPD FROM TO FWATPRIAL i EMPLACEUIENT METHOD&ANOVNj
Non-Water Supply Well: rt,
I k4,"le tv i
olvionitoring ORecovery L4 ft. fr. A&A
Injection Well: I
oAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(ifairiplien it)
DAquifer Storage and Recovery 0 Salinity Barrier FROM TO i,�TEPRAL EMPLACEMENT 141E T HOD
DAquifer Test ElStormwater Drainage ft. It. I
ElExperimental Technology oSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(aftnih additional sheets if necessary)
FROM TO DrSCMTION(color,hardness,soil/rock type,grain sizc.cic.)
oGeothermal(Heating/Cooling Return) 00ther(explain uAnderA#21 Remarks)
4.Date Well(s)Completed: Well ED#Arrj-3 7 ft- ft-_ t c (,-)I !e7cey
5a.Well Location: Phone # 1*,r-
KvZe Mee,-ka,4 46.1 ft. Ar. d �A; e
FacAy/Owner Name Facility D:)#(if applicable) ft. ft.
fj ft. ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS
County Parcel Identification No.(PIN)
56.La-titude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N 2 2 2- w 11511/
Signature of Certified Well Contractor Date
6.Is(are)the well(s): dIrmanent or OTemporary
Bji signing this fo)-ii),Ihei,ebj,cei-lifj,that the it,ell(s)mas(wei-e)constructed inaccot-doi?ceii,iili
7.Is this a repair to an existing well: Oyes or Xo MA NCAC 02C.0100 or 15A NCAC 02C.0200 Kfell Construction Standards and that a colry
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 ivell owner.
repair tinder 921 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-- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6T
For multiple wells list all depths ii'different(example-3@200'and2@100') Submit this GW-1-within 30 daysof well completion per the following:
24R. For All Wells: Original forni to Division of Water Resources (DWR),
10.Static water level below top of casing: 160 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
J Bit Off: 24b. For Injection Wells: Copy to DWR,Underground Injection Control (lUQ
11.Borehole diameter: Program, 1636 MSC,Raleigh,NC 2 699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-)Loop Geothermal Return Wells:Copy to hp
(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�100,600 GPD- Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,INC 27699-1611
13a.Yield(gpm)-3.,Ya Method of test:
70%HTH Oz DATE SITE VISITED: 2-
13b.Disinfection type: Amount:
ors
VISITED BY:
Form GW-I North Carolina Devartment ofErivimitme'aw n-ut.