GW1-2021-00289_Well Construction - GW1_20211213

• NVELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
J_ 1.Well Contractor Informntion:
,eml War *1--3 14.WATER ZONES C\
FROM TO DESCRIPTION
Well Contractor Name_ //�� ft 110 ft Z 0 NA
� 1� fr. 1So ft. $'C�
NC Well Contractor Certification Number 15.OUTER CASWG(for multi-cased wells OR LINER rf a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TfficlorEsS MATERIAL
fr. ft. in.
Company Name 16.INNER CASING OR TUBING( ectherma]dosed-loo )
2.Well Construction Permit#: (J /"j t t/ FROM TO DIAMETER I TKICIINESs ruTERIAL
List all applicable well construction permits rL C,County,State,Variance,etc) ft ft- �p m. SoR ` A VC
gas G O a D
3.Well Use(check well use): ft fr. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIOVESS MATERIAL
❑Agricultural ❑Munieipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lnigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft' 14air D{-j PoureJ 3
❑Monitoring ❑Recovery 3 fL 33 ft. O•Act Graf,* eumiq 3 ba
Injection WelI- fr fr
[]Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑$fllinity Bon 19.SAND/GRAVEL PACKdalicableier FROM TO MATERIAL EMPLACEMENTMLTHOD
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Reto n) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION error,hardness,soiltmrk type, .'n size,ere.
o ft. 9 S ft. s
a�
4.Date Well(s)Completed: (I 19 11I Well M#AX10" 00 91r ft. 22L ft- G C4^•te
fL
5a Well Location:
Phone #3 -44 * ft _
rr. ft. _ \
ft ft
F r*1O Na1m�e �j^ / / Facility ID#(if applicable) ' �.
Lo T- ( j�yCt-G d Dri�/sy ft. ft,
Physical Address,City,and Zip IL Lam!Psi Try ft. ft
���++�� 21.REMARKS
County �+` Parcel Identifoation No.CKN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
N g/ l�.l�j W
6.Is(are)the well(s):Xermanent or ❑Temporary Signatke of C rtified Well Contractor Date
1,0. By signing thisform,I hereby cert6 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ,e•xv o 15A NCAC 02C.0100 or 15A NCAC 02C.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 to the well owner.
repair under f21 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 needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled; 2 24.SUBMLTTAL INSTRUCTIONS
9.Total well depth below land surface: )7]. (ft.) Submit this GW-1 within 30 days of well completion per the following:For multiple wells list all depths If different(example-3(c�200'and 2©100� y P P
S`v 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.5tatic water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaier level is above casing;use"+"
f Borehole diameter: (in.) Bit Off: I•o-1 Q 24b.For Injection Wells: Copy to DWR,Underground Injection Control(11JC)
11. 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
13s.Yield m _7 Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gP ) o
13b.Disinfection type: 70%HTH Amount: Q OZ DATE SITE VISITED: g•- �l
�� VISITED BY: ��