GW1-2021-00016_Well Construction - GW1_20211109

VTELL CONSTRUCTION RECORD (GH-11 For Internal Use Only:
1.Well Contractor Information:
a 14.WATER ZONES
PROM TO DESCRIPTION
Well Contractor N e / /_,91. //y H.. y
y3 v ft. g4wft. I aaaP#
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER tf a ticahle
YADKIN WELL COMPANY,INC. FROM To DIAMETER THlc[avEss MATERIAL
ft. ft in.
Company Name 16.INNER CASING OR TUBING 'eothermal dosed-loop) .
2.Well Construction Permit#: FROM TO DIAtY IM= THICCIEayss MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) + PITY- v
ft. ft. in. m
3.Well Use(check well use):
W er Supply Well: 17.SCREEN f-.
pp Y FROM TO DIAMETER SLOT SIZE THICK IA
THICKNESS MATERL
'cultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d ft. CO ft. 'P"- ' nD udco0
❑Monitoring ❑Recovery Tt ?m s1-Jf v-- d/
Injection Well: g, g.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R' fE
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheets if necessary)
Fft
Ao
TO DESCRIPTION color,hardness,so
il/roek 4 grain stu,cte_
❑Geothermal(Iieating/Cooling Kelton) OOthei(explaYin�under#21 Remarks)4.DateWell(s)Completed: v -a Well ID#/l ' " ® if�• ft' ��' S5a well Location: Phone # - �r®•7� 7 R �L�� GO-& ,� D, �,e �� ,,.4
Famlity/OwnerName Facility ID#(if applicable) %
ft. ,s�ft.
Physical Address,City,and Zip " C ,F"'s (�r-,
21.REMARKS i
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: riV"
(ifwell field,one lat/long is sufficient) 22.Certification: �i', A hT
1r' ,��. qZ� N �C7b W -
6.Is(are)the well(s): l�rmanent or ❑Temporary Si of CereKd Well Contractor Date
By signing thisform,]hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or W, 15A NCAC 02C.0100 or 1 A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well conduction information and explain 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:
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 Gri is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 6 24.SUBMITTAL INSTRUCTIONS 7�
-
9.Total well depth below land surface: 6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 r©200'and 1Q100D \
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: rP5- (ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 1
Ifwaier level is above casing,use"+' tt 1
Bit Off: D• ��r 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
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
(Le.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: 't'
o C��� DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZ
VISITED BY: P '