GW1-2021-00135_Well Construction - GW1_20211213

E T,'+CON51 RUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
/ ' i I �CJA t- •CgeA.V-e 14.WATEit ZONES
Well Contractor Name ,Q FROM TO I DESCRIIPP`TION
E /
ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells OR LINER i£a livable
YADKIN WELL COMPANY,INC. FROM To DIAMETER I TMCMMS MATERIAL
ft. ft in.
Company Name �+/ 16.ReM CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit#: J,?rjr V7 ® FROM To DIAMETER THICKNESS AIATERIAL
List all applicable well construction perin�e UIC,County,State,Variance,etc) ftrl r7ft C.0 5 in. D/J 1 VC,
3.Well Use(check well use): ft ft. C. in. J U"1 fX v
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
❑Agricultural ❑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>1007000GPD FROM TO MATERIAL EMPLACEMMTnIXTHOD&.AMOUNT
Non-Water Supply Well: A £t. �' ft. ��o `���� 01 il aA ®ta.rtst
f
❑Monitoring ❑Recovery ft g e
ft. A^ G .�� � f
Injection Well:
S rr
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery' ❑S 19.SAND/GRAVEL PACK if a licable)
8linityBamer FROM TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater DrainageT.
it ft•
❑Experimental Technology ❑Subsidence Contibl ft it
❑Geothermal(Closed Loop) ❑Tracei 20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Heatiag/CoolingRamn);., •;pother(explain under#21 Remarks) FROM To DESCRIPTION cons,hardness,smvrock r; sae ec�
ft
. ft. Qtz
4.Date Well(s)Completed: 114.1'u2-� Well ID# ` o �R. � (� R. f
\,,. i
5a.Well Location: Phone #
lAI FAG/tee 2- ft ft
Facility/OwnerName Facility ID#(ifopplicable) ft. ft•
ft. ft
Physical Address,may,and Zip ft ft.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one iat/longis sufficient) 22.Certification:
3�® 10J7 N el m 3177y
W
6.Is(are)the well(s): A'ermaneut or ❑Temporary Signature of Certified Well Contactor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an erdsting well: ❑Yes or A'`_ 15A NCAC 02C.0100 or 15A 14CAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and erplain the nature of the of this record has beer 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 is needed. Indicate TOTAL NUMBER of wells (add'See Ovcr'in Remado Box).You may also attach additional pages if necessary.
wed'•- 60
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'annd 2@100)
it 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft)) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" //'
11.Borehole diameter: (0 (in,) Bit Off: 6 ' 0 24b.For 11 lection 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
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells yroducingLver 100,000 GPD:Copy to DWR,CCPCUA
r-- Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test:
13b.Disinfection type: �sI
7o%HTH Z DATE SITE VISITED:_/A®