GW1-2021-01847_Well Construction - GW1_20210503

CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
'% OCA,' inulliy 14J.WATERZ0NES'
Well Contractor Nam FROM TO DESCREPITOK
4
7'2,0'
NC Well Contractor CertificationI Number 15.�OUTER CASING(for :d* OkLgg%iftialkible).�_
FROM -:� T_o Vfl� S
'11h
YADKIN WELL COMPANY,INC. VLDIA! TER MATERIAL
ft. ft. in.
Company Name I I I
Dow kv 16.INNER CASING OR TUBING.(gi6thi�imil,ct6seil;I60P
2.Well Construction Permit#: mom TO DIAMETER TRICIMSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) "L 579 /;L In— er ' P'le,
3.Well Use(check well use): ft. ft. in. J4 C>
-
Water Supply Well. 17.SCREEN '
FROM TO DIAMETER SLOT SIZE THICXNESS I MATERIAL
ElAgricultural OMunicipal/Public
CGeothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
01ndustrial/Commercial OResidential Water Supply(shared)
18.GROUT
olnigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 164'f ft. Do U
oMonitoring CIRecovery Yt. 27 . Ls�
Injection Well: ft, ft. V
DAquifer Recharge OGroundwater Remediation
19.-SAND/GRAVELIP.AC-K-,(if--iii6liabli)'
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMFLACLMENT NIM THOD --
OAquifer Test CStormwater Drainage ft. ft 0
ElExperimental Technology GSubsidence Control ft. ft.
CGeothermal(Closed Loop) OTracer
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardne3s,suittrock type,grain size,etc.)
0 ft' 5�- ft. Jro 1 0/
4.Date Well(s)Completed: Well IDAM-V_7 2, 50 ft /�O
ft. ft.
Sa.Well Location: Phone #J_Y�,,0 706_Z
Z-.AA",
Facility/OwneAame If Facility]D#(if applicable) ft. ft.
31qe-,u irl I ft. ft.
M0 C*s&JU�__ I?
Physical Address,City,and Zip ft. ft.
21.REMARKS
imp
County Parcel Identification No.(PIN) �ng
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: proCes,
(if well field,one lattlong is sufficient) 22.Certification: DW R U 11
41 af
6.Is(arc)the well(s): Wermanent or OTemporary Sie of Cej�Ad Well Contractor Date
y rgng thisforin,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: CYes or Zo 15ANCACO2C.0100or15ANCACO2C.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 i've/l owner.
repair under#21 remarks section or on the back of this farm.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Sce Over in Remarks Box).'You! may also attach additional pages if necessary.
drilled: 24.SUBMITTAL E14STRUCTIONS
9.Total well depth below land surface:
ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
a00 (ft 24a. For All Wells: Original form, to Division of Water Resources (DWR),
10.Static water level below top of casing: .) Information Processing Unit 1617 1MSC,Raleigh,NC 27699-1617
if water level is above casing,use
11.Borehole diameter: (in.) Sit Off: (3 0 24b.For Injection Wells: Copy to DWR, Underground Injection Control(lUQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method- AIR ROTARY 24c.For Water Supply and Open[Lo:ov 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�-ver 104,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,1 9-1611 tAl IdUA,-
70%HTH
13b.Disinfection type: OZ DATE SITE VISITED:
Amount: I
VISITED BY:, r) ._r ti I
Form GW-I North Carolina Department ofEnvironmeatal Oualitv-Divisinn of Watpr P­­­l