GW1-2021-06377_Well Construction - GW1_20210915

b `ITJi�a,\\, �1�T�1iR'1� CTION RECORD (GW-1� For Internal Use Only:
f... r
I.Well Contractor Iniormation:
t-n S 14.WATER ZONES
> Well Contractor Name -•; FROM TO DESCRIPTION
I ft. p lq fr. ►s GPre►
li p r aL4D A R. ft
NC Well Contractor Certification Number ^-
15.OUTER CASING for multi-used wells ORLDVER if a ticable 0
" YADKIN WEL(I=COMPANY,INC.' FROM To DIANIIiTER THICKNESS MATERIAL
�Itv` ft fr. in.
Company Name 16.INNER CASING ORTUBING eothermal closed-loo
2.Well Construction Permit#: �� y� FROM TO DIAMETER THICIt1VESS MATERIAL
List all applicable well construction permits rLe.WC,County,State,Yartance,eta) R 61
if I�$, 1°' �9' QV(
3.Well Use(check well use , fr. R. m
Water Supply Well; l7.SCRE>N.
�..
PP Y ^'' I7tOM 7'O iu DIAMETER 'SLOT SIZE THtCfOYESS MATERUIL
❑Agricultural ❑Municipal/Public ft w:'.R. ' in;
❑Geothermal(Heating/Cooling Supply) Paesidential Water Supply(single) in:
❑Industrial/Corrrercial ❑Residential Water Supply(shared) !tt<OROUT f%
❑Irrigation ❑Wells>100,000 GPD MOM,c t, To, MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O^;;
OMonitoring ❑Recovery
Injection Well:.: fr ft
❑Aquifer Recharge ❑Groundwater Remediation ,' = Y.
i 4191SAND/GRAVEL PACK if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier jIj 1FROM TO; MATERIAL En�LACEMENr nsEraon
OAquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control ft ft.
❑Geotllermai(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessd (\ 3
FROM TO ; DESCRIPTION color,hardness,soiYrocktypr,grain six etc.).
❑Geothermal(Heating/Co oling Return) ❑Other(explain under#21.Remarks)_
D. _ft. 3S ft.
e-1 OK
4 Date Wells)`Completed: 2 �^ well ID# 0� �D 35 R 3 SAft'
y ft ft.
5a Well Location: PhOnet OiQlr—:1 3"Z' _ ft.
liat aG �
Facility/Ovmec Name Facility ID#(if applicable) ft• ft
e'
{` ft R.
l/i 15 �� as z
Physical Addiess,City,and Zip ft fr. l
�ibtr J-
-
eo°nty Parcel Identification No.(PIN) a
process!
5b:Latitude a Ond longitude in degrees/minutes/seconds or decimal degrees: � n I
(ifwell field,one let/longis sufficient) 22,Certification: D ~1
3 ff A., rG o W O j Z 2
Sign a re ofCerped Wag Contractor Date
6-Is(are)fl ewell(s):.Permanent or `❑Tempo=iiry`
Bysigning thisform,I hereby certify that the well(s)was(were)constructed in accordance with
t 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
1 7:Is this a repair to an 6tisting well ❑Yes of AN
t: - this record has been provided to the well owner.
If this is a repair,fill out m6wn well con
struchotr informalron and explain the nahire of the °f
repair under#2!remarks sifdil6n or on Bic back of this forni.
t 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
^traction;only 1 GW71 Is need Intlicate TOTAL NUMBER of we1Ls ,,;, ( S ) You may also attach additional pages if necessary.
add See Over in Remarks Box).
24 UBMMAL INSTRUCTIONS
9.Total well depth below land surface: 3143 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdjferent(example-3 r0200'and 2@1009
24a.',For All Wells: Original.form to Division of Water Resources (DWR)
10.Static water level below top of casing: I0D ,f(ft-) Information Processing Unit,161740C,Raleigh,NC 27699-1617
If water level is above casing,use .��
Bit Off: 24b.For Injection Wells:Copy o DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY f
12.Well construction method: 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
t� FOR WATER SUPPLY WELLS ONLY: 24d.For_Watec Wells producing!over 100,000 GPD:Copy to DWR CCPCUA
Pemut Program,1611,MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
•,� irk
•a.-'70%H T H 1.l OZ DATE SITE VISITED:`
L1315.Disinfection type: Amount: 1� 3
`dam VISITED BY:
North Carolina Department ofSnvironmental Quality-Division of Water Resources ReYised 6 6-20)8