GW1-2021-04226_Well Construction - GW1_20210415

. f _
r
i
i
i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �
C
1.Well Contractor Information:
tiL'inn L)town _ 14.:WATER ZONES I ;
Well�ContractorNaamre \ FROMft " y ft t2 RIITTON
30 J A �� ft. .0 ft. /^ "
NC Well Contractor Certification Number 1
J j it I5.OUTER GR C (for multo-cosed wells)OR LiNCR if a licable
FROM TO DIAMETER TffiCHQVES MATERIAL
YADKIN WELL COMPANY,INC. V�11
- , y,9Fa mn ft. ft. in.
! 1
iv
Company Name 1�i 0it�`; q9_d` B 16.INNER CASING OR TUBING(&otherma]closed-loop)
2.Well Construction Permit#: l/S 14 F i�L !�� •-Zy 2( FROM TO DIAM�/�/ETER THICHIVESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) 1 ft. t�"l ft. 6 i& in.
3.Well Use(check well use): H ft. a ft. in J fl
Water Supply Well: 17.SCR)vEN
FROM TO DIAMETER SLOT SIZE TffiC[OVESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEIAENT METHOD x ANIOUi[T
Non-Water Supply Well: ft. 3 ft. .�N r -
❑Monitoring ❑Recovery ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK 017a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL MPLACENIENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(ntMch a(ditional sheets if necessary)
❑Geothermal(I-Ieating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,cic)
4.Date Well(s)Completed: 3- Z 1 Well ID4 A A0 a?7 k l L ft. .2 � ft. 5J
5a.Well Location: Phone # �.� f- aZ 23 3v ft- Ad J-/ i
Facility/Owner Name Facility ID#(if applicable) 6 6t'1 ft. �C Z ft. S-Sri/L
�
5149 14w r � �� �?�a�v�i � ft. ft.
Physical Address,City,and Zip
f l ti O_ 21.RENIARKS /
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longg its sufficient) �i ? q ® 22.Certification'
6.Is(are)the wells) Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance iviih
7.Is this a repair to an existing well: ❑Yes or )RIPO ISA NCAC 02C.0100 or hA NCAC 02C.0200 Well CanStllCGOn Standards and that a co/?P
If this is a repair,fill out known well construction infonnation and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box)!.You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCT IEONS
9.Total well depth below land surface: ®O�_ (ft.) Submit this GW-1 within 30 dlays of well completion per the following:
For multiple wells list all depths ifel erent(example-3(200'and�21Q100')
10.Static water level below top of casing: 6 t/ (ft.) 24a. For All Wells: Originally form to Division of Water Resources (DWR),
10.Static
is above casing,use op infonnation Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
Ifwater 11.Borehole diameter: (in,) Bit Off: 6, 013 24b.For En.jection 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 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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1-2- Method of test:�� U
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: S
M If I VISITED BY: ��L v
_