GW1-2021-00275_Well Construction - GW1_20211213

WELLJ S ll 1RUCTIQN RECORD(GNV-1) For Internal Use Only:
1,Well Contractor informntion:
+^ 14.WATER ZONES I
73 C� y V FROM I TO I DESCRIPTION
Well Conbactor e t Zr ft. AD Rl �Q
?7�t' /7 it /p � 3Z- 33- 5/D
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca weDs OR LINER if applicable)
MAL
YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATE
p ft. ft. in.
Company Name Cc J J j e-,4 6 Z J?-- Z S-'Vcl 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: by-7 FROM TO DIAMETER TfficlavEss MArERiAL
it. is M r
� List all applicable well construction permits(i.e.UIC,County,State,Variance,etc ft.
) /
ft. in
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIOVESS MATERIAL
❑Agricultural 019nicipaVPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft. in
'V ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT rn
❑Irrigation ❑Wells>100,000 GPD FROM TO MATEIt1AI EMPLACEMENT METHOD&AMOUNT
Q Non-Water Supply Well: a ft. r ft. im
v�tl�
V ❑Monitoring ❑Recovery elft 10'r 4/
Injection Well: ft. ft '
../ ❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
[]Aquifer Test ❑Stormwater Drainage ft• it.
4 '
[]Experimental Technology ❑Subsidence Control
�S ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FR TO DESCRIPTION rzlor hardness,solttroek ins" etc.),
I ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadcs) r0 O .ft• r f.
/gyp /+Q� b tJ�
4.Date Well(s)Completed: O- Well m# A Gs - �•� 47 7 00 ft' aWr1� 'i ofe �•
V Phone # "772- -30C� 90fL ds ft• '"�%'�►'
5a.Well Location:
�0 9 it yp ft. �
Facility/Owner Name Facility M9(if applicable) Q ft it
nIC NOS
nr �dt � ��a 1 r I - ft ft
Physical Address,City,and Zip i #
C'l(A fv i(/� 21.REMARKS
21
County
Parcel Identification No_(PIl� O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
! 5•�oCWell Contactor; ate
6.Is(are)the well(s): gf ermanent or ❑Temporary
By signing thisforrn,1hereby certify that the well(s)was(were)constructed Inaceordrnbewith C
7.Is this a repair to an existing well: ❑Yes or 1 /0 ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction,Standards and that a copy r
If this is a repair,fill out known well construction information and explain the nature of the
of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form. 23.Site diagram or additional well details-
-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 -1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: C3 C O (ft') Submit this GW-1 within 30 days of well completion per the following:,
For multiple wells list all depths if different(example-3@200'and 2Q1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: L,'0 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
/ Bit Off: s.�y�r 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) ,
11.Borehole diameter: `4 (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
(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 produci Ig over 100,000 GPD:Copy to DWR,CCPCUA
,,,
Pen-nit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) &0 Method of test: e ,
70%HTH 9 OZ DATE SITE VISITED:Qfj.�1-Zt
13b.Disinfection type: Amount:
------- .. -- VISITED BY: 4 y P
Revised64-20I8