GW1-2021-01493_Well Construction - GW1_20210415

JLIL CONSTRUCTION RECORD (OW-1) For Internal Use Only: C
1.Well Contractor Information:
_ ✓ \ �(/ L► Owe 14.WATER ZONES t I
Well Contractor Name � FROItI T4 DESCRIPR ION
IV' ,9r1ft. ���� it. C�
E f/V ft. ft. � r
NC Well Contractor Certification Number f1 15.OUTER CASING for multi-cased wells)ORLINE-x if a `licuble
YADKIN WELL.COMPANY,INC. APR `� 2Q2� FROM TO DIAMETER THICKNESS K&TERIAL Gr
ft. ft. in.
Company Name fGCL'fi J'
e'q 0 1nfoim3t y_Ction 16.INNER CASING OR RING geothe'rroal closed-too )
2.Well Construction Permit#: '� Z� � PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc..) ,#. ft. ft. f in. ,�2 t Q / (�
SD
3.Well Use(check well use): ft. 6 ft. •�+ in. 7 v v
Water Supply Well: 11.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural O1Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) dkKesidential Water Supply(single) ft. ft. in•
OIndustrial/Commercial OResidential Water Supply(shared) iti.GROUT
OIrri ation ❑Wells>100,000 GPD rROM TO MATERIAL EMPLACEMENT METHOD Fe AMOUPIT
Non-Water Supply Well: O rt. L# ft.
OMonitoring DRecovery ft. ft. t
Injection Well: T
ft. £t.
OAquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PAC hti.(if a liciible),
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage
DExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20."DRILLING LOG attach additi4nal`sheets if necessary
$ '' FROM TO DESCRIPTION color,bordness,soil/rocic e,arvn si c,etc.)
OGeothennal(I-)'eating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft f G1"
k 44:Date Well(s)Completed: 2�=;^9t Well ID# /Ke.1 iA/01 A4G
. `. 5a.Well Location: Phone # 3SZ 'Y<C! g J ft. ft.
Facility/Owner Nkine FacilliityyIID#(if applicable) ft. ft.
'Ile ft. ft.
Physical Address,City,and Zip ft. ft.
2I.REMARKS
County V� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwclI field,one lattlong is sufficient) 22.Certification:
6.Is(are)the weil(s): !&7Krmanent or OTemporary Signature of Certified Well Contractor ! Date
// By signing this form,I hereby certijJ,that the well(s)was(were)constructed to accordance with
7.Is this a repair to an existing well: DYes or iVo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Krell Construction Standards and that a colrl,
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 Nell owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details: I
8.For Geoprobe/IDPT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necossar.
drilled: J ' 1 l 24.SUBMITTAL IINSTRUCTIONS
9.Total well depth below land surface: &•� (ft.) Submit this CW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierem(example-3 c@200'and 2 t@100')
v 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ,r a
11.Borehole diameter: (in.) Bit Off: 66�,' 1 Ll 14 24b.For Injection Wells: Copy toGDWR,Underground Injection Control (TUC)
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 zile
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where in IIed
FOR WATER SUPPLY WELLS ONLY: 24d.1For Water Wells producing o,vei•100,600 GPIID: Copy to DWR,CCPCUA
®� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: j
13b.(Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:2-k
- VISITED BY: i
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