GW1-2021-00219_Well Construction - GW1_20211213

CQNSTRUCTION RECORD (GIN-1) For Internal Use Only:
1.Well Contractor In
formation:
6106)in/A 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
_ S Q 3 to A 01 ft. )9 S ". 31- MAIM
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased4ells OR LIPIER if a cable
YADKIN WELL COMPANY,INC. FROM To DIAIYIETE THICKNESS MATERIAL
ft. in.
Company Name 7�_ (A 16.INNER CASING OR TUBING` ' the closed-loop)
2.Well Construction Permit#:419 - .c >-cs� of FROM To IDL4M, ER Tffi9CIINESS MATERIAL
List all applicable well construction pennrt s(Le.UIC,County,State,Variance,etc.) + l ft- // ft l 1D' 6oG.�d I
3.Well Use(check well use): fr' fr' '- in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICIMSS MATERIAL
❑Agricultural ❑Municipal/Public
Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it.
P.Wial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT �)
ym*gation ❑Wells>100,000 GPD PROM I TO MATERIAL EMPLACENIENT METHOD&AMOUNT `J
Non-Water Supply Well: 6 ft. ft. ^�,
❑Monitoring ❑Recovery 3 ft. d -ft. 4) M
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a liable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM EMPLACEMENT OD
❑Aquifer Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed hoop) ❑Tracer 20.DRDLI NG LOG attach additional sheets if necessary) , (Q
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiltroek c in sae,.0 �1 l
�( V ft. ?S- ft. P�q.
4.Date Well(s)Completed: ,® '"Z 6 Q)! Wel'l-7 N tD.�V 9 „�s fr' �C®k ft- Sly (,& Ae.--,A ifack
5a.Well Location: Phon F -70 V-� : e� tp& ft 4- 6 n &
eJ ft. ft Faoility/Owneritame Facility ID#(if applicable) ft. ft'
Ode,siti or_ s-&A L 4( ft. ft. PEC 2021
Physical Address,City,and Zip ft ft.
�leg CQ Sl�� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlongti fipient) gyp-® 22.Certification;
S�rl. j N .S'�. !- 5[ W /D- e?G-- a
6.Is(are)the well(s): BPermanent or ❑Temporary Signature of Certified Well Contractor Date
-! By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t�1Vo 1 SA NCAC 02C.0100 or 15A NCAC 02C.02 00 Well Construction Standards and that a copy
If this is a repair,fill out!mown 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 jto provide additional well construction info
construction,only 1 G�-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 100 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(n)200'and 2©100D
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
Ifwaier level is above casing use„
Bit Off: 6 /.Z 1 eJ 24b.For Injection Wells: Co
11.Borehole diameter: � (in.) pY to D WR,Underground Injection Control(IUC)
NO;' 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
(i.e.auger,rotary,cable,direct push,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
13a.Yield(gpm) -7 0 Method of test: r j Permit rogram,1611 MSC,Raleigh NC 27699-I611 70%HTH OZ DATE SITE VISITED: 2-U -TN�1tt
4
13b.Disinfection type: Amount:
,.,,-1 1n Pam. ,,