GW1-2021-05577_Well Construction - GW1_20211013

CONSTRUCTION For Internal Use Only:
1.Wel Contractor Informntion:
�2 Ie
a r 1 yq�I 15r0 con <\N 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
T%ti • it. a ft. r -7 s v_ U-z
3036A ZJ� r�\ 70 ft. q 7
NC Well Contractor Certification Number ?�G`'e��p 15.OUTER CKASING for multi-used wells OR LINER rf a licable
YADKIN WELL COMPANY,INC. ,^,^ FG FROM TO DIAMETER CIINESS MATERIAL
p� 1� ft
Company Name �/µ�(t '3 3(7, �° �- 7Q\ 16. R CASING OR TU13ING eothermal closed-loop)
2.Well Construction Permit#: W S A r O e Z 6%0 2-%-)2 FROM To DIAMETER THICIadESs I MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ,F / ft• 6 ft. ! in. _ e ! �C
3,Well Use(check well use): ft, ft. ! to do r
Water Supply Well: F SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ ft
MMunicipal/Public . ft,
d in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
❑Induatrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
❑Monitoring ❑Recovery it a ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMEl'HOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling RetLim) ❑Other(explain under#21 Remarks) FROM To DESCRtMON color,hardness,soil/rock typr,grain sae,etc
0 'L J-7 ft' s .'/
4.Date Well(s)Completed: '-/0 Well ID#AA d`"7a -s- 7 ft• aoq ft- 2 �{>�
5a.Well Location: Phone ,37,E 'Z 6Vft 36 2 ft.
ft. &
Facility/Owner Name /� Facility ID#/(if applicable) ft
P -akys, R I 19aoAV11/tom.. ft ft.
Physical Address,City,and
21.REMARKS
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification: Q
J&" &. C1 3-k N Y 3 7. T��jj FO W
6.Is(are)the well(s): Q'Permanent or []Temporary Signature ed Well Contractor Date
r/ By signing thisform,l hereby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or o 1 SA NCAC 02C.0100 or i5A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information and&plain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same C
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.
drilled; �f ° 24.SUBMITTAL INSTRUCTIONS
2 [
9.Total well depth below land surface: ✓ v/` (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells ILtI all depths if different(ezample-3Q200'and 2Q700D
/� 24a. For All Wells: Original.form to Division of Water Resources (DWR),
�✓ 9
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: V ° 0 e ( 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) _
Program,1636 MSC,lWeigh,NC 27699-1636 c
AIR ROTARY
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
j •�
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA `
'1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) V Method of test: r W a°ct.,,wf S�
OZ DATE SITE VISITED:
13b.Disinfection type: 70%HTH Amount: Ol
PrirP-
VISITED BY: -ir-afu,