GW1-2021-05324_Well Construction - GW1_20211013

For Internal Use Only:
1.Well Contractor Information:f �q
/(� V�' a A° '3 B 19.WATER ZONE,y vim. FROM TO DESCRIPTION
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Well Contractor Name B t
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NC Well Contractor Certification Number l)�1 1 2 ry ,OUTER CASING for mulfi-cased wells ORLIIVER if a licable
YADKIN WELL COMPANY,INC. p�OOeSS`n 7 FROM TO DIAMETER ft' I ft I in. THICKNESS MATERIAL 0
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Company Name D��TR 16.INNER CASING OR TUBING eothernsal closed400
2.Well Construction Permit#: 7 7 9
FROM TO DIAMETER TMCICNESS NIATERiAL
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List all applicable well construction pei�nifs(i.e. C,County,State,Variance,etc) 4- f. 6 ft' .2 in. ,? �G
3.Well Use(check well use): ft. ft. in.
17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL r �.
❑Agricultural ❑Municipal/Public ft. fr. in.
❑Geothermal(Heating/Cooling Supply) A sidential Water Supply(single) ft. ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT --��
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT a
Non-Water Supply Well: ® ft. 4 ft. LPL tv �� (A re
❑Monitoring ❑Recovery fL 2 ft• �k/ Ae
Injection Well: ft, JFL
❑Aquifer Recharge ❑Groundwater Remediation d
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '®
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑EScperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) color,hardness,soiUroek e .iu sae,etc 4.Date Wells)Completed: �` �a.t. Well ID# 1� " ley R' 41 fi' rGGkfL
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5a.Well Location Phone #lDf 7V 10
Facility/Owner Name Facility ID#(if apphealile) 0 ft' 0 ft SPA e
ft ft.
Pell
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Physical Address City,and Zip a URW 15 M ft ft I�/tt tH 1TG o a
21.REMARKS L
;County Parcel Identification No.GMq) r D� (d
5b:Latitude and longitude in degrees/mrnutesMe'conds or decimal degrees: -k �'� l f
(if well field,one IaUlongis sufficient) r� 22.Certification: /pry
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6.Is(are)the well(s): rermanent or ❑Temporary Signature of Certified Well Contractor Date
_ By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well' ❑Yes or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy Al
IJthis is a repair,fill oul known well construction information a4dexplain the nature of the of this record has beenprovidid:o the well owner. \_
repair under#21 remarks section or on the back of thisform. 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 N
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. y
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0Q (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths 1f different(example-3(a)200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level belowltb'p of casing: D® (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 f,;�
If water level is above casing,user'-'*"
Bit Off: 1 J 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in.) 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)_.3�; Method of test: Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
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70%HTH � OZ.r. DATE SITE VISITED: ! S"e� t
13b.Disinfection type: Amount-
VISITED BY: y J