GW1-2021-00190_Well Construction - GW1_20211213

WEt-rC ONS T R UC T ION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
" � rJ'� 14.WATER ZONES
Well Contractor N-ne FROM TO
ft. DESCRIPTION
33 0ft.
.� �a A k�ft. ft eZ 7
NC Well Contractor Certification Number !n?
15.OUTER CASING for multi-rased wells ORLINER if a Iicable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER T8r SS MATERIAL
j� ,,(�`` ft. in.
Company Name &*4" ZpT' r`3 ' r�V 16.INNER CASING OR TUBING(geothermal closed-loo )
2.Well Construction Permit#: /-7 .) "t FROM TO DIAMETER Tmcromss 11uTERIAL l
List all applicable well construction permits(ie.UIC,County,State,YarlanM e(a) ,f, ft. 7 it %• in. r� ry eV
3.Well Use(check well use): in. J aC
Water Supply Well: 17.SCREEN ..r..�
FROM TO DIAMETER SLOT SIZE TffiCI(lYESS MATERIAL �OJ
OAgricultural ❑Municipal/Public it, ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it in
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT _
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACEMENT ATETOOD&AMOUNT
Non-Water Supply Well: ft. ft. &afe,i�c
,r
❑Monitoring Recovery ft P ft. r , • � u ./
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a linable)
❑Aquifer Storage and Recovery ❑Salitlity Barrier FROM TO 1V TERIAS, EIKPLACEMENT METaOD
❑Aquifer Test ❑Stormwater Drainage it.
❑Experimental Technology ❑Subsidence Control ft it.
❑Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Heating/Cooliag Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/mckitype,grain Sim,otL
4.Date Wells)Completed:11 3 a L wenm#AAA- 7! b /Y 7 ft' o,.2 ft• Cyr ,'
5a Well Location: ft ft
w � t5
Phone #q8o� ,�22� �6 � -
ft. ft
Facility/Owner Name 1 Facility ID#(if aatppplll__iccaLable) ft, ft.
s 7.� R.aae-V i ttc.i T`y'_ 6�(/1�,9 /'iT�� ��- ft. ft. -
r
Physical Address,City,and Zip ft it.
21.REMARKS
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
.35`�
' !/ � N * ` 17,z z So 3 w
�Z�,
6.ls(are)the well(s): L9Permanent or ❑Temporary Signature of Certified Well Contractor Date
ire C Z signing thisfonn,]hereby certify Oct the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarkr 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 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTI IAL INSTRUCnCNI3
9.Total well depth below land surface: u 1 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list a1l depths if differen((example-3Qa 200'and 1®I001
s'� 24s. For All Wells: Original form to Division of Water Resources (DWR), -
10.Static water level below top of easing: (ft.) Information Processing Unit,1617 NISC,Raleigh,NC 27699-1617
Ifwoter level is above casing,use"+" Bit Off: a q o 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-) Program,1636 MSC,Raleigh,NC 2'i 699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the \�A
(i.e.auger,rotary,cable,direct gush,etc.) county environmental health department of the county where installed "
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing;over 100,000 GPD: Copy to DWR.CCPCUA 1
13a.Yield(gpm) 0 Method of test: /V,tV C,//' Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH a' y OZ DATE SITE VISITED: /O
13b.Disinfection type: Amount: _ -
p�-4 re-
` rr VISITED BY:�-