GW1-2021-00119_Well Construction - GW1_20211109

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LL CONS T1 IUCTION RECORD (GW-1) For Internal Use Only:
1,Well Contractor Information:
1� ,�} Inr1l1 XWATER20NES
Well Contractor Name FROM TO DESCRIPTION
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*30 ft. 1,3 ft 1
NC Well Contractor Certification Number 301,
{� f 15,OUTER CASING formu]fi-rased wells ORLIIVF.R E32 livable
YADKIN WELL COMPANY,INC. — �� ' l/ FROM D ER ITffiCIOVE MATERLtL
- m J Company Name 16.RTSIER CASING OR TUBING eothie closed-loo
pp
2.Well Construction Permit#: FROM TO DIAMETER THICIINE.SS MATERIAL V
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List all applicable well construction permits(4e.UIC County,State,Variance,etC) ft ft J J in. n
3.Well Use(check well use), ft. ft in. ~�
Water Supply Well: 17.SCREEN
FROM TO DIAMETERI SLOT SIZE THICIOYESS I MATERIAL
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) g, ft. in. 60��
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: O ft. ft• ? !. ^
❑Monitoring ❑Recovery 3
Injection Well: 21
U�t^
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL En1CPLA 'MENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft it
❑Experimental Technology ❑Subsidence Control ft
❑Geotht rural(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CoolingRettrm) ❑Other(explain under#21 Remark) FROM To DESCRIMON color,hnrdness,x0rocx type,grain:izr,etc
ft dn.Z ft' S�
4.Date Well(s)Completed: ,0`d�'aZ 0 WeII ID# �' �`7 ft ;y It v /l
sa Well Location: Phone #09-4re -J&So J-9 ft 32Jr ft A.Al G �v
Facility/OwnerName IllA(if applicable) 6
3g3o A!6 C0%tac D-tr `y Are son ft
Physical Address,City,and Zip IF %Wft ft 2 Q 21
21.REMARILS 66 a
County Parcel Identification No.(PIN) s T/ JQ la I a "i^ wG t e C
�C;Jv'ti'uU Vi ii I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
F337 N KI 4 G.S3Sf w 4-n -.2k,ZL6.Is(are)the wcU(s): kermacent or ❑Temporary Signature of Certified Well Conine or Daft
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AD 15A NCAC 02C.0100 or 15A NCAC 02C.0200 mell Construction Standards and that a copy
If this is a repair,fdl out Imown well construction information and explain the nature of the of this record has been provided to the Nell owner. K
repair under i21 remarks section or on the back of this form. 23,Site diagram or additional well details. ' `a
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 needgd. Indicate TOTAL NUMBER of wells (add'See Over'in Remm im Box).You may also attach additional pages if necessary.
drilled: y+/ 24.SUBMITTAL INSTRUCTIONS a
9.Total well depth below land surface: (ft) R ,
For multiple wells list all depths If different(examp/e-3Q200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
o
S-0 ) 24a. For All Wells: Original fort to Division of Water Resources (DWR),
f Static water level below top of casing: (ft Information Processing Unit;Ifwoter level Is above casing,use"+" g ntt,1 617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 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 Operi-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,mobile,direct push etc.) county environmental health departrnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD: Copy to DWR,CCPCUA
laa•yield m Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gp ) �, Method of test:
70%HTH 36 OZ_ DATE SITE VISITED:
' 136.7isinfection type: Amount: _ _