GW1-2021-00284_Well Construction - GW1_20211213

N ONril SUCTION RECORD f GW-I`1 For Internal Use Only:
1.Well Contractor Inforrantion:
^ep Of j"U I(J. 14.WATER ZONES \
Well Contracti)r NaAr TROM TO DESCRIPTION (V�v
ap/ ft, ft. O
.01
NC Well n�Cerhfiication Number /y /tf g ft •
15.OUTERCASING forniulfi-case s ORLINER(if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TffiQQVESS MATERIAL
ft ft. in.
Company Name (,_3 , 3 XG
a 6S2-® 16.INNER CASING OR TUBING eotherma]closed-loop)
2.Well Construction Permit#: FROM To DIAMETER TffiC04LSS MATERIAL
List all applicable well construction permits(i a UIC,County,State,Variance,etc) ! it ft • ��Srn. t,1 �,� S�
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE- TMCICNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. ft. in.
[]Geothermal(HeatinglCooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Comr�ercial ❑Residential Water Supply(shared) 73
18.GROUT !
❑ ❑Irrr ation Wells>100,000 G -
PD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT 0
Non-Water Supply Well: ft, ft.
❑Monitoring ❑Recovery 3 ft O e ft.
Injection Well: ft ft. -
VAf
❑Aquikr Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPIaCEMENTMETHOD
❑Aquifer Test ❑Storrowater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neCe9Sa
❑Geothermal(Heating/CoolingRetun) ❑Other(explain under#21Remarks) FROM To ' Dasc�Tlox �ter,ta,aa�s,.,ovro� ;as;u.t�
O ft• Si ft• S'c."L
4.Date Wells)Completed://- 9•;/ Well ID# .�� 2 ft'' �3rI ry�f •
5a.Well Location: Phone #,VC• 2.62- $Oki 13Y ft P'Oi'tt Meal 10YY- 41 e4 C
%AJ h ft ft
Facility/Owter
[Name / p �j Facility M#(if applicable) / ft ft. ( C
/S- 7 k- L c.a F /ri h /c..ta. J0 h d x, A(C �i 67� ft. ft
Physical Address,City,and ZiP ft I ft.
21.REMARKR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/longis sufficient) 22.Certification.
6.Is(are)the well(s): Qxrmaneut or ❑Temporary Sigueorr of Certifi ell Contractor Date
_1� By signing thisform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or & o ISA NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction SYandards and that a ropy
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 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 Ove?in Remada Box).You may also attach additional pages if necessary.
drilled: 24.SUBMPTTAL INSTRUCTIONS
9.Total well depth below land surface: eZ0 • (ft)
For multiple wells list all depths lfdi)ferent(example-3@200'and 2®1000 Submit this GW-1 within 30 days of well completion per the following:
i
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
lfwater level is above casing,use"+"
11.Borehole diameter: 6 (in.) Bet Off: .1• 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchiR over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Q� Pit Program,1611 MSC,Raleigh,NC 27699-1611
� S � /� Permit
OZ DATE SITE VISITED: "2
VISITED BY: Q