GW1-2021-00270_Well Construction - GW1_20211213

WELL CONSTRUCTION N RECORD(:GW-i1) For Internal Use Only:
1.Well Contractor lnforrnntion:
Al CIS
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name j /
NC Well Contractor CertificalionN-11-
15.OUTER CASING for nou7li-cased wells ORLINER if a licable
_ •YADKIN WELL COMPANY,INC. FROM To nIAIVIItTER TMCE:NEss MATERIAL (\
ft. ft. in. `(!
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 7 �.(p 17 S FROM TO DIAMETER I TMEHa F1,S MATERIAL
List all applicable well construction permits(r.e.VIC,County,State,Yariance,etc) ft Sin 'it I
3.Well Use(checkwell use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICa1NESS MATERIAL
❑Agricultural ❑Municipai/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• ft. in.
❑Industrial/Commercial residential
Water Supply(shared) 16.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTAMTHOD s AMOUNT
Non-Water Supply Well: ,o ft. ". {n'¢G� �t
❑Monitoring ❑Recovery ft ft.
Injection Well: vgi Id M life-d
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVEL PACK rf a licabie)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EA LACEMZNT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. ICCZ
❑Geothermal(Closed Loop) ❑Tracer- 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Rehnn) ❑Other(explain under#21 Remarks): FROM TO n n ESCRtPox(coloi;har edn s,:oiuroelr • sys,etr
ii 0 ft' ft. S-6171
4.Date Well(s)Completed: 1- ` Well ID# -W-AG S ft' t ft' /bp t,,/
5a.Well Location: Phone # X-J-g`:.6a^`l-503 ft tt f
[r! kfft ft
/lJ ,
Facility/Owns Name Facility ID#Cif applicable) ft ft
C 1 b3 &!&4v ft ft.
i
Physical Address,Ciin and ZV ft ft
21.REMARKS
'Couty(y.' Parcel Identification No.(PET)
fib:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one iat/longis sufficient) 22.Certification' q
6.Is(are)the well(s): [yermanent or ❑Temporary Signature of Certified Well Contractor Date
Ey signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 1 SA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Construction Standards and that a copy
repair
is a repair,fill out known well construction 6rformation d erp/a n the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 OW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).'You may also attach additional pages if necessary.
drilled: ` Z4.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / f/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths jf&fferent(arample-3©200'and 2®1000 \
�®
E 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.., a 24b.For Lkiection Wells. Copy to DWR,Underground Injection Control(ILTC)
Il.Borehole diameter: (in.) 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 producing over 100,000 GPD:Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7 Method of test: ( )
13b.Disinfection type: 70%HTH Amount: 1 OZ DATE SITE VISITED:
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VISITED BY: