GW1-2021-01848_Well Construction - GW1_20210503

-WrrL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
14.-IWATER"ZONES
Contractor N c
b
FROM TO DESCRIPTION d0'ft. .3e4& ft' 6)p
Wefl'- f:n
0�57,2-,J' C'
NC Well Contractor Certification Number
.15.OUTER CASING'(fd-r.T"-"I "sed.'iFe1qWLrNER!,(if AlliEibli
YADKIN WELL COMPANY,INC. FROM TO DIArvIETER I THICICITESS MATERIAL
Company Name -2 kO ft.
o a,Le- 16.INNER CASING'OR'�T.UBING!(gi�o-thiii.ifiil,clo�siid-'Idb'6)--�.���
2.Well Construction Permit#: -% 3-7 e)r,:z FROM TO DIAMETER THICKNESS MATERIAL`
List all applicable well construction permits(i.e.07C,County,State, Variance,etc.) It. in. 6"1V
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN-"FROM I To DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OM "cipal/Public ft. ft.
DGeothermal(Heating/Cooling Supply) 7.,idential Water Supply(single) ft. ft.
oIndustrial/Commercial ciResidential Water Supply(shared)
.18.7GROUT
ClIrrigation EiWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
DMonitoring oRebbyery ft. ft. 19 I'A�5-10f 04
7
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation
49.SAND/GRAVEL
DAquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ElAquifer Test oStormwater Drainage
DExperimental Technology oSubsidence Control
oGeothermal(Closed Loop) E]Tracer '20sDRWLI G tOG'0fffirCh-2d di 66iiil'ffieie&.'i fib 6cei!fi'6)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) I FROM TO DESCRIPTION, (color,hardness,soillrock type,grain sin,etc.)
Well ID#.. (2 ft* //ff,- 5�611 J- t-A"./
4.Date Well(s)Completed: - NEI- //V ft- 23 0 ` 0/ -w
Sa.Well Location: Phone # SCq- _?C(S T V CCrl ?3
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Aduv ft. ft.-RE V 1J
Physical Address,City,and Zip ft. ft.
21.,REMIARKS 3 Z117 3 Z117 3 Z117
County Parcel Identification No.(PIN)
proces
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
3S r x '7o6 N 90" Z16. OF/
�W
6.Is(are)the well(s): Wermanent or OTemporary Sign of CeWd Well Contractor Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance with7.Is this a repair to an existing well: OYes or 0 4/0 15A NCAC 02C.0100 or 15A NCAC102C.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 I 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: ft
Submit this GW-1 within 30 day s of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
Bit Off: 5" 970 24b. For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 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 producingiover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh NU 27699-1611
13a.Yield(gpm)_I?- Method of test: Q/'P. I I C--e-j4n, fev'I'A
70%HTH ?X4/./ oz DATE SITE VISITED: 2-1
13b.Disinfection type.: Amount: cl .--a I
VISITED BY: 3 b�
Form r' J<:��J-1 Qevised 6-6-?0,4
W-1 North Carolina Department of Quality-Division of Water Resources A