GW1-2021-00261_Well Construction - GW1_20211213

(tE��,�°'+CbNS 1RUC7CION RECORD (GW-1) For Internal Use Only:
1.Well C'oonnt/trr,Jactor,Infornintion:
7//1Z In/ APV 1 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION �
30364 4 7s ft. *7
ft, it.
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells ORLINER if ap licable
YADKIN WELL COMPANY,INC. FROM LOITER Tffi s MATERIAL
Company Name n 16.USINER CASING OR TUBING eothermal closed loo
2.Well Construction Permit#:P9 VL dq V a I V A 914 FROM To DIAMETER Tfficzavrss MATERIAL
List all applicable well construction permits(te.UIC,County,State,Variance,ete.J 41 ft /'7 R G r/2 in. (}�/��� 6.01V 5,14,Ce
3.Well Use(check well use): ft ft. in.
Water Supply well: 17.SCREEN
PP y FROM TO DLAMETIM SLOT SIZE TEICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(sing]e) ft in,
❑Iudustrial/Cornmercial ❑Residential Water Supply(shared) IS.GROUT
❑Isigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ,
Non-Water Supply Well: ft. tl
❑Mrmitoring ❑Recovery .3 ft a?V ft ik .�, i ,•.
Injection Well: ft R
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applivable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEPIAL EMPiACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage it.
❑Experimental Technology ❑Subsidence Control ti• f
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/CooUng Return) ❑Other(explain tinder#21 Rematics) FROM TO DESCRIMOx colon hardness,x0rurk e ' {ve,ctr-
qq pp,,�� 9ftt.
a ftSO4.Date Well(s)Completed: '111 '4 wellm / AO-7s� 1/U ft.Sa Well Location: Phone #_Mr YJJ'r'!tr s-6 it'! Y ft
ft. ft
Facrlity/Owner Nam Facility IDA(if appHosblc)
©(
Physical Address,City,and Zip ft ft``''
�"✓' Irc)L10- 6U-3Z�� 21.RF.MARKG \./
County Parcel Identification No.(PIN zP•.P e V t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification'
A �9i �// N
6.Is(are)the well(s): Germanent or ❑Temporary Signatrrre of Certified Well Contractor Date
✓/ By signing thisform,I hereby certify that the well(s)was(were)constructed in accordm ce with
7.Is this a repair to an existing well: ❑Yes or MI 15ANCAC 02C.0100 or 13ANCAC102C.0200 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 fo 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 Over'in Remada Box).'You may also attach additional pages if necessary.
drilled: 24:SUI3NUITAL INSTRUCTIONS
9.Total well depth below land surface: JI-0 I (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd)femnt(example-3@200'and 2@1001
24a. For All Wells: Original 'fo to Division of Water Resources (DWR),
10.Static water level below top of casing: ®® rm(ft.) Information Processing Unit, MSC,Raleigh,NC 27699-1617 QJ
Ifwater level Is above casing,use"+" `�
f Borehole diameter (O (in.) Bit Off: 6, `r 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11. 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
(Le.auger,rotary,cable,direct push,etc) county environmental health dep I'artrnent of the county where installed
G
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test: t -Ile p
o 7 P �
13b.Disinfection type: 70/o HTH Amount:� OZ DATE SITE VISITED:
VISITED BY: 6q