GW1-2021-07094_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD LQW-D For Internal Use Only:
1.Well Contractor Informntion: -1
14.WATER ZONES I i
Well Contractor lan IROM ft. TO DESCRIPTION
a+ A
NC Well Contractor Certification Number is.OUTER for mu1H-cat`sed wells'OR LINER if a livable
YADKIN WELL COMPANY,INC. FROM TINGTO DIAMETER THICKNESS MATERLAL
ft. ft in. _
Company Name ��,� ✓r7f 3 3G • fo - r-T 2-s
16.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: PA VJ L 20 2( O ( 7 J ft FROM TO DIAMETER THICKNESS MATERL\L"
List all applicable well construction permits(i e.WC,County,State,Variance,etc) ft• -7S ft. J - n• ✓rAR 2- y,G
3.Well Use(check well use): ft. in'
Water Supply Well: 17.SCREEN i
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑�M�unicipal/Public ft. ft. ;in.
❑Geothermal(Heating/Cooling Supply) 19Residential Water Supply(single) fr. fr. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑1rrigati0n ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We11: p ft. ft• Bei'1 L° At 4!V
❑Monitoring ❑Recovery
�- on•Sluvr
Injection Well: o- ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 33
19.SAND/GRAVEL PACK if 2pl�livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under.#21 Remarks) FROM To I DESCRIPTION color,hardness smltroek Ain sae,etc
d � S".r ft. •`�.
4.Date Well(s)Completeii: _Well ID# ft' Q ft. P&16®fBP
5a.Well Location: r/ Phone #-SJC-710 T.'p9 0-7 fL ��¢t + s 4. t
Faeffity/OwYer Name IFacility ID#(if applicable) T70 ft- t�•�,'ft W A�J �d
it Z? Dom- A;G( R� ft.PVJ- Md-h.. ft.
Physical Address,City,and Zip ft. ft GK
21.REMARKS a •`
county Parcel Identification No.(PIN) �O (72-
5b.Latitude bind longitude in degrees/minutes/seconds or decimal degrees: v �' lltlll6
(ifwell field,one lat/longis sufficient) 22.Certification: SSCYlOII
X4 23. 7 Y 9 N ROJ 2cf. I -
.4P;;t->f
6.Is(are)the well(s): llil�ermanent or ❑Temporary Si2oafa of CeriKed Well Contractor Date
By signing thisform,I hereby certify that the welt(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or do 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 ramarks 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�is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.C
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (R') 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@100)
�� ft: 24a. For All Wells: Original If6rm to,Division of Water Resourcesr(DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617 NCC,Raleigh,NC 27699-1617
lfwaier level is above casing,use
Bit Off: 24b.For Injection to D
11.Borehole diameter: (in.) Wells: Copy WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 4 " 'k-
24c.For Water Supply and One Loop Geothermal Return We11sd 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 produce ig over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 9 Method of test: >'t 124
Permit Program,1611 MSC,Raleigh,NC 27699-1611 aI
� � { $c
e: 70%HTH Amount: OZ DATE SITE VISITED: 7"2.7�
13b.Disinfection - Z � r-
h! All
T)ri r•ca-
VISITED BY:
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