GW1-2021-07087_Well Construction - GW1_20210915

Wirm-ICONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: -q'
14.'WATEWZONES w
F'�•� 7r a FROM TO DESC TION `
W 1 Contractor ame
ft. 1-7 ft , r«eLl®rf� �''��` 4
���• �`p 1 e7 r v. { L✓� TTs /►'1
NC Well Contractor Certification Number C r r""
".� 1 15.OUTER CASING fo�molti=casedivells�ORLiNER tf5`••lic'able�' �
YADKIN WELLCOMPANY,INC. FROM TO DIAMETER THICIINESS MATERIAL
1�, ft. ft. in.
Company Name, 'yo/1.X Yw .3 3`� ��
16.INNER CASING OR'TUBING',(gebtheim&ddsed=ldo
2.Well Construction Permit#:r 1 F 0i 7`(jam ��QL FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(re.-vx-counry,state,Variance,etc.) ft. ft. 4 yT in.
r
in.
3.Well Use(check well use): 17. E EN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
bicultural': ❑Municipal/Public ft. ft. in.
h
❑Geothermal(Heating/Cooling Supply). $ 5idegtial Water Supply(single) ft. ft. in• 9
❑Industrial/Commercial ❑Residential Water Supply(shared) GROUT
RGgition ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Will:
❑Monitoring 'ORecovery
evv
Injection Well:
ft. ft.
❑Aquifer Recharge „'DGroundwater Remediation
19.SAND/GRAVEL PACK ifa"livable
❑Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEIaIENT METHOD
DAquifer Test DStormwater Drainage
❑Experimental Technology -PSubsidence Control
❑Geothermal(Closed Loop) ❑Tracer '20.+DRTULING LUG attach additionil:.sheets'if•necesia'
FROM TO DESCRIPTION color,hardness,soiUracls e, rain size,etc.)
❑Geothermal(fleating/Cooling Bettor) 00ther(explain under#21 Remarks) /111 ft. ?.Vft. t
4.Date Well(s)Completed: Well ID# - �75 3f J1 K• 530ft• /e ft-Ae-
SirQ ft. loVd ft.
sa.w a�,oeaa Phone #,a,�-- �!/�� .�'S`��
�ss+�i''t '�° to a ft• q raft. /? o�J
Facility/Owner Name Facility M#(if applicable) �®tt, v Xt. / ►I"ir m, 4 `,. 4
/ ( ' ft. ft.
2ay I jtiL�l -�_ 1 s c)_._. ��d ki yi lei
Physical Address,-Citf and Zip
IN 21.RGIVIARKS
County Parcel Identification No.(PIN) Q 3©�
5b.Latitude and longttude,in degrees/minutes/seconds or decimal degrees: &y®
(if well field,one lat/long is sufficient) 22.Certification:
J o T :N ® r� W ✓ Q/ 7
/ r Si re o P ted Well Contractor Date
6.Is(are)the well(s): [WIrmanent fior Temporary
By signing this farm,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well lives or *'LVo 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 construc
repair under#21 remarks section or on the back`pftioii,iriformatlon and explain the nature of the of this record has been provided to the well owner.
this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed Loop Geot hermal Wells having the same You may use the back of this;page to provide additional well construction info
1.construction,only I GW-1 is needed. In dicate TOTAL NUMBER of wells
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:"- � 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f J Oo� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 1Q100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casings (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwatei level is above casing,use +"
11.Borehole diameter: (in.)'
Bit Off: 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 Oven-Loop Geothermal Return Wells:Copy to the
(i.e.auger,iotary,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}CCPC A
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611 �dvt�jo4lY6,y - v
13a.Yield(gpm) �®� Method of test-
�.`�
r-2/ i�csyllrei
13b.Disinfecti 70%HTH OZ DATE SITE VISITED:on type: Amount: 7,rS A04 `PA`J
VISITED BY: �
Form GW-1 ^^ -_ North Carolina Dep ent of E ton ntal Quality Division of Water Resources E t% 1 ;�,� Revised6--2013
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