GW1-2021-00290_Well Construction - GW1_20211213

c�J+COINS TRUCTHON RECORD LGW-41 For Internal Use Only:
1.Well Contractor Inform ition:I '[ t
J ecry WC OW 1-S 14.WATERZONES
FROM TO DTSCRIPTION
Well Contractor Nameft.
�Li � A ft. I`S'S f'. 3 10M
NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells ORLWER rf a Gcable t
YADKIN WELL COMPANY,INC. (,� FROM To DIAMETER Tffi[savEss MATERIAL
ft ft.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM I To I DIAMETER --J-T-EaC10MSS--LK&T-MUAL
List all applicable well construction permits(te.UIC,County,State,Variance,etc) e l G in.
3.Well Use(check well use): ft, w
17.SCREEN
Water Supply Well:
pp Y FROM TO DIAMETER SLOT SIZE THIctOYEss MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) JVesidential Water Supply(single) ft. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hTl ation ❑Wells>100,000 GPD FROM TO `MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' S PFO �k POur� 3 II
❑Monitoring ❑Recovery it 'S 4*e54 PA�od a P4
Injection Well: g fL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL.PACK(if a 1uable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERL I EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control fL R•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIlHGLOG attach additional sheets if necessary)
FROM TO DFSCPMnION color,hardness,soiltrock c, tin sae,cte
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under#21 Remarks) 0 ft. S ft,
t e
4.DatL�Well s ompTeted:-���� well ID# `l� 75- R' 190 ft' 6
5a.Well Location: 'SD
Phone # 3 -q�l 3Z ft fL
ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft.
-
1 Bf PAi '10#s Ilan• ono ryw' NC ft It
Physical Address,City,and Zip ft. ft . 3 9'
toll,& 21.RETAARKS
CS
copy Parcel Identification No.(PIN) -
Sb.Latitude and longitude in degrees/iminutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
3l D4�. 75�7 N 8Y l5; !F?q2 w (te a 113v�
6.Is(are)thewell(s): Aermanent or ❑Temporary Signature f CertifiledWellCantzactor Date
By signing thisfarm,thereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1I0 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repalr,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair wider$21 remarks section or on the back ofthisfonn. 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 Remadcs Box).You may also attach additional pages if necessary.
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drilled: [ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ldiferent(example-3 c©200'and2®1000
570 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing use "+"
Bit Off: textI'• 24h.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.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\
(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
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 50 Method of test: :qd le h'
13b.Disinfection type:
70%HTH Amount Gi OZ DATE SITE VISITED:
:
VISITED BY: `/�