GW1-2021-00018_Well Construction - GW1_20211109

WfM--f0_9_S7L7UC 1T1+C N RECORD ('GW-1) For Internal Use Only:
1.Well Contractor Informsxtion:
� i rr u 1 �� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor N e ®ft o ft /sue
I A-
off, -7 ft ?I
NC well Contractor Certification Number r �'�"
15.OUTERCASING forniulti-uasedw s MMER(if livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THIt3 MS MATERIAL
ft ft. in.
Company Name 3
16.RUiER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit 9: FROM TO DIAMETER THICEnNFa5 MATERIAL
List all applicable well construction permits(Le C,County,State,Yariance,etc) 1 R e, ft r ,01)'t• .S P
3.Well Use(check well use): ft ft. in.
Water Supply Well-, 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERL4L
OAgricultural ❑M al/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) 11�Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑IIn ation ❑Wells>100,000 GPD FROM I TO DATERIAL EMPLACEMENT]METHOD&AMOUNT
Non-Water Supply Well: d ft. ft 9P'n' ;as ®✓��
❑Monitoring ❑Recovery ft ft. Pil. v r v f�
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation �.
19.SAND/GRAVELPACK da livable) @®,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test .❑StormwaterDrainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRMLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Coolmg Return) ❑Other(explain under#21 Remarks) FROM TO DEsCR=OX color,hardness,safl/rocktypc,gr.uusize,etc
4 ,
4.Date Well(s)Completed:�-a�Well ID# �' fie ft �.
/-78-Q 1 ft tz
5a Well Location: Phone #__v(,j. ( C2F?Z -eW` -0 pf e 4'
JC3/tCi tre��Z. 13,0 ft (oZJ � n� A y
Facility/OwnerName ( LFa�cility M#(if applicable) /� ft. f
14'60 4l+e[n�l �" ✓ l►�41�fV � ft ft
04
Physical Address; ,and Zip ft ft ►' t e,C C? /
r-..-..
County Parcel Identification No.R N) %1 ty'k 4%t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: NOV ''
(if well field,one lat/longis sufficient) 22.Certification �i `C2A'ti+ t
�t 42A;��ALi& ILDO�N PROCESSii
6.Is(are)the well(s): ermaneut or ❑Temporary Si of C ed Well Contractor Date
By signing thisfarm,l hereby certify that the well(s)was(were)constructed in accardmuce with
7.Is this a repair to an existing well: ❑Yes or ItK0 15A NCAC 02C.0100 or 1.iA NCAC 02C.0200 Well Construction SYmudards and that a copy
Ifthis is a repair,fill out lmown well construction urformatlan and eVlain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. �
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�is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: a� 24.SUBMITTAL INSTRUCTIONS Q,t
9.Total well depth below land surface: eg 6.7
For multiple wells list all depths!fdiferent(example-3©200'and2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ` ,r I (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaier level is above casing,use"+" ® information Processing Unit,1617 MSC,Raleigh,NC 27699-16I7
11.Borehole diameter: (in.) Bit Off: or 24b.For Injection 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
(Le.auger,rotary,cable,direct push,eto.) county environmental health de i artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) _ Method of test: /dd• 11 Permit Program,1611 MSC,Raleigh,NC 27699-1611
T �'
13b.Disinfection type: 70%HTH Amount: �eo 7 OZ DATE SITE VISITED;:y�7 2-7 '2.
VISITED BY: 13,�[�