GW1-2021-08125_Well Construction - GW1_20211109

WEtL CONS 17ke11JC T ION RECORD(91-l-i1) For Internal Use Only:
;.Well Contractor Informn-tion:
� ll p 1�
t r 6 f U G +� ✓ 14.WATER ZOICI S
Well Contractor Name PROD TO DESCRIPTION
NC Well Cantractor Certification Number 15,OUTER CASING farniuIti-cased wells)ORLINER if a licable
YADKIN WELL COMPANY,INC_ FROM TO DIAMRTER TB C IMSS MaTFRIAL
ft. ft. In.
Company Name 16.INNER CASING OR TUBING( eothermal dosed-loop)
2.Well Construed on Permit#: an 10 PROM TO DIAMETER I THIcxNrss I n4ATmuAL
List all applicable well construction permits(4e.UIC,County,State,Variance,etc) + ft ft. C. 1 15+ 1A'
3.Weli Use(cbeckwell use): ft, ft. in.
Water Supply Well: I7.5CREEN
FnoM TO bIAMEfJ±R SLOT SIZE TSlCIWTi.55 MATERIAL
❑Agricultural ❑Mhmicipalil ublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) —. ft. ft. In,
❑IndustriaUCommerciai ❑Residential Water Supply(shared) 18.GROUT
DIrrigati0n ❑Wells>100,000GPD VROM TO MATMAL EMPLACEtyMNTn4ETHOD&A]KOIINT
Non-Water Supply Well: it 3 ft. t �f _k. S r/t'
DMcnimring DRecovery 3 ft ft. ¢f �C �f A.
Injectiou Well: d
ft it.
❑Aquifer Recharge ❑Groundwater Remediation
19.39ND/GRAVEL PACK(if a ficable
DAquifer Storage and Recovery DSalinity Barrier FROM TO TYMTEMAL En1PLACEMENT METHOD
❑Aquifer Test DStormwater Drainage fL
❑Experimental Technology []Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.ARILLING LOG attach additional sheets if necessa
❑Geothermal(Healing/CoolingRetum) ❑Other(explain under#21 Remaiks) FROM TO nEscm ON color,hardness,soiurutk e, n size,err.
f)
4.Date Wells)Completed I�"1` Well)D# -' 1-13 �/ ft' 7�,L
5a.WellLocation: Phone # ���^�'����-�� 3� ft, ft
ft ft
Facility/OwnerName Facility ID#(ifawlicable) ft' 3 ft !'' i ;� !
Uj
��r1 � �° � ft. " ft. (1�JT Iywn 111 d
Physics,City,and Zip ft. fL
/ 2L RUWARICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one iat/longis sufcient) 22.Certification. 7�i21
N W
�Ul� 4�... G-,�C411ii i o— I L N
6.Is(ar e)th e w ell(s): 'permanent or ❑Temporary Signature of Certified WellContrdctdrl 1H�:lAT1'0NPROCFSSN'TuN•
vidlt
By signing this form,1 hereby certify that the well(T)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or Io 15ANCAC 02C_0100 or 15ANt:AC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out)mown well construction information and explain the nature afthe of this record has been pravided to the well owner.
repair under*22 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 nee(Ied. indicate TOTAL NUI FMER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary,
drilled: L k 24.SUBMrr AL INSTRUCTIONS
9.Total well depth below load surface: (ft) Submit this GW-1 within 30 days o£well completion per the following:
For multiple wells list all depihs ifdi1erent(example-3(a)200'and 2 c@r 1000
242. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levi'-I below tag of casing: / vJ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if-wafer level is above casing,use
c j Bit Off. 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 ofthe county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) o
(�+ Method of test: Ig/ttl Permit Program,I611 MSC,Raleigh,NC 27699-I611
70%HTH OZ DATE SITE VISITED: '
13b.Disinfection type: Amount: �J�
VISITED BY: V 1, (eF-e i
Fnrm rw-I i d, 1 North Carolina Deoarhnent nvrronnte cality-Division of Water Resources P evicr.ri F_F_an t u