GW1-2021-00017_Well Construction - GW1_20211109

)N RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information: `
s 19.WATER ZONES I
" 1
Well Contractor Name FROM TO DcESC ON
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LAVER tf a licabl:IAL
�•/
YADKIN WELL COMPANY,INC. FROM To DIAMETER THTCIINESs MA
y ft. ft in.
Company Name ®av 1 ti ,3 7 T J [FL 16.INNER CASING OR TUBING 'eothermal closed-loop)
2.Well Construction Permit#: �- / gr FROM To DTAhILfER TffiCKNESS
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) to (Z�3{ /i..
ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOT SIZE I MATERIAL
❑Agricultural ❑M�unicipal/Public tt. fr. in•
❑Geothermal(Heating/Cooling Supply) R}Residential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
❑Monitoring ❑Recovery ft
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
W�'
TO DESCRIPTION ealor hardness sailfrock G ain sae,cto
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ytft4.Date Well(s)Completed: -v I well mi f�-40 - 63 c � fL t�f� �a t�C ' �-o,fL Sa Well Location: PhOns # 7Q'2•ZX22.Io .!
Facility/Owner Name Facility ID#(if applicable) ft. ft y \`
_ ft ft
Physical Address,City,and Zip
21.REMARKS
" i0
l e—
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3';1 S'fs. G0 79 w
�.// Si of Ce • d Well Contractor Date
6.Is(are)the well(s): C�Permanent or ❑Temporary gn
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1 SA NCAC 01C.0100 or I5A NCAC,02C.0100 Well Construction Standards and that a copy C
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#11 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 GTI is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attacb additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �V (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 and 2Q1000 (�
° 24a. For All Wells: Original,form to Division of Water Resources (DWR), A
10.Static water level below top of casing: "S (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: S � 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigb,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:CopyJo DWR,CCPCUA
d Permit Program,1611 MSC,Raleigh,NC 27699-1611 tat,v
13a.Yield(gpm) Method of test: r
70/o
o HTH OZ
qq DATE SITE VISITED: 7-2d'2-1
13b.Disinfection type: Amount:
VISITED BY: I7