GW1-2021-00120_Well Construction - GW1_20211109

` L+ oNS 1'R11JCTION RECORD(GIV-1) For Internal Use Only:
1.Well Contractor lnformntion: L
3e`(y k A]Q T 1�I�1 S 14.WATER ZONES
> '- FROM TO DESCRIPTION
WeA Contractor Name:S] ft ft
j y 5 ft. ft-
Well Contractor Certification Number 15.OUTER CASING formulfi-rased wells ORLINER rf a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICl�IESS MATERIAL
ft ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: w FROM TO DIAMLTER TMCIINE.Ss I MATERL4L
List all appllcabli'i,el/construction permits(ie.WC,County,State,Yariance,etc) ft ft in.
3.Well Use(check well use): R• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DUMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft tt. in.
uIudustrial/Commercial residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: tt• 8.
❑Monitoring ❑Recovetj.� ft ft.
Injection Well: 8 fL
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑S�y gamer M SAND/GRAVEL PACK der liable
FROA4 TO MATERIAL I EMPLACEML+NTMETHOD
❑Aquifer Test ❑Stormwater Drainage R- it.
❑Experimental Teebnology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
❑Geothermal(Eieating/Cooling Retum) ❑Other(explain under#21 Remazics) FROM TO DESCRIPTION color,h,ranen,saiYmc r y • �tic
ap fr. 3 03ft. '6an-mvie
4.Date Wells)Copleted:./01 al b I Well W#L O-Z ft ft �]
5a.Well Location: ,, I Phone # t-3 ®- S�2o /-
IK tW"k � �'L7�o f6� ft ft
�, / j• r
Facrlity/OwnerNama �`::� F�acilifyID#(ifapplicable) ft R
1 51O &.&k iJ�.P'7'�• ,-�"w�eaa' c����s ft ftNOV 9
Physical Address,City,and Zip ft ft.
G� Zl.RRMARKR
County PamelIdentifioatioallo.(PIld)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
r
N � Z 2` 3 ®, W 10 1 a7 1 a 1
6.Is(are)the well(s): Apermarrent or ❑Temporary SignatnretfCerqed Well Contractor Date
By signing thisform,I hereby cer*that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or /Io 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifth!s 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#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 GW 1 s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages 1f necessary.
drilled: C 24.SU13N=AL INSTRUCTIONS
9.Total well depth below land surface: 3 D3 (fL) Submit this GW-1 within 30 days of well completion per the followin
For multiple wells list all depths Ifdierent(example-3©200'and 1®100D Y P P g
24s. For All Wells: Original form to Division of Water Resources (D)YR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater lave!Is above casing,use"+" `
11.Borehole diameter: P (in.) Bit Off: �S 40` 24b.For Injection Wells: Copyb to DWR,Underground Injection Control(RJC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health depalrtment of the county where instalIed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin?g over 100,000 GPD: Copy to DWR,CCPCUA
m
(gP ) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield �G✓
13b.Disinfection type: 70%HTH Amount: S'� OZ DATE SITE VISITED: dp- •+�
Dr•
VISITED BY: �p