GW1-2021-01849_Well Construction - GW1_20210503

-WrVi,CONSTRUCTION RECORD (GW-1) For Internal Use Only: `
1.Well Contractor Information:
�� ' •14.�WATERZONES :: F 1
Well Contracto Name FROM TO IP DESCRTION i
-7- 7 ft. , ft. .rl �C NL
NC Well Contractor Certification Number
15.OUTER CASING'ftii:multi;cae'ed•wells`.OR TINER if;a`"
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICIINESS MATERIAL
ft. ft. ! in.'
Company Name p�a�ie, 'b3G- 7r3- 6T�rl�
16ANNER CASING OICTUBING eothe�mil,blosed=l6o"
2.Well Construction Permit#: 2 3(- R I $ FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ' ft. ft. /•1>5-in•
3.Well Use(check well use): fr. ft 1� in.
J /
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑fMMunicipal/Public fr. ft. ;in.
❑Geothermal(Heating/Cooling Supply) V esidential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) _ 4
18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. s' tr. p„•'C 4iLJu rr�
❑Monitoring ❑Recovery ft. 3-6` ft-
Injection Well: tr1•S�f! U/'�
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.^SAND/GRFiVEL-EACK'if a"`licablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage. ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.7DRrLLING,LOG"attaccti dddiiib6ifs6eiti if-,fecessa' `
FROM TO DESCRIPTION color,hardness,soit/roch type,grain•size,etc.
❑Geothermal(11eating/Cooling Return) ❑Other(explain under#21 Remarks) ft. SM fr. �C
4.Date Well(s)Completed: -�!♦- �L Well ID#
5a.Well Location: fr• ft.
e f / Phone # 331a 30(1
Facility/Ownerft
Name (' 1 Facility ID#(if applicable) . ft.
IL I)
7"�q
ft. ft
Physical Address,City,and Zip
/� 21.REMARKS i r.
V CLV 1 B- I e ve.�1 G b-wit �.�tIQ� rif �11 W
County 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:
6.Is(are)the well(s): Wermanent or ❑Temporary Si o ert' Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
do7.Is this a repair to an existing well: ❑Yes or 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 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: I 24.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 3 a (ft-) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths if different(example-3©200'and 2 r@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,161'7 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: .07X 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
I
E ,
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
11 • Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method of test: �
13a.Yield(gpm) d O r p 0
13b.Disinfection type:
70%H Amount:
TH OZ DATE SITE VISITED: Lt* le 2-1 t e A4
VISITED BY: IJ/�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2013