GW1-2021-00292_Well Construction - GW1_20211213

i
NUJL-a QNSTRUCTI N RECORD EYED For Internal Use Only:
1.Well Contractor Information:
�� � � is✓ se w� 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name s1s'� ft. �7 ft. v (�
f l
3036 A 4 ft. ���ft. J
NC Well Contactor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a lieable
YADKIN WELL COMPANY,INC. FROM To DIAMETER L.
7MClOMS MATERIAL
ft in.
Company Name w t ( 3 ' 6 ar Z v' 19.]INNER CASING OR TUBING(geothermal dosed-lop
2.Well Construction)Permit#: a> Z FROM TO DIAMETER TffiCKNFSS MATERIAL _
List all applicable well construction permits(I.e.WC,County,State,Variance,etc) ft aa��f' ft t/ in- S - e7( PV
3.Well Use(check well use): fr. in• i
77.SCREE EN �
Water Supply Well: rROM TO DIAMETER SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. in 4
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) 7
f ft. in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 3 fr• •-A. '►
�r
❑Monitoring ❑Recovery S ft 1 ft•
Injection Well: ft fr•
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDIGRAVEL PACK(if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. LACLMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft, ft'
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUmtktypc ain sae,etc
ft V fr. Ji'i e.
4.Date Well(s)Completed: o� Well ID# zd . ,v
5a.WellLocation: Phone #CRY- 3(2-- GVI I ft fta(y-. I kT_93- y -
ft. ft
Fac�iltty/Owner Name Facility ID#(if applicable) ft. ft. --
��c.� M P E C 1 3 202'
ft ft
Pbysical Address,City,and Zip �j
ly%l k S �Aft S4�(• 21.REMARKS
County Parcel Identification No.CPIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/loag is sufficient) 22.Certification:
Signature of Certified Well Contractor Date
6.Is(are)the well(s): C3YCrmanent or ❑Temporary
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing ®SVo well: Dyes or 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
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#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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 C 24.SUBMITTAL INSTRUCTIONS `
9.Total well depth below land surface: _2d 2_ (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3 c©200'and 2©100)
e0 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 [�
Ifwoter level is above casing,use"+"
Bit Off: (� _1 24b.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 pusb,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 DAIR,CCPCUA \
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) /06 Method of test: /+I3/ 4//�d. p, �
eat',
+f U _
13b.Disinfection type: 70 o�0 HTH Amount: I OZ l
DATE SITE VISITED: / r</
VISITED BY: 0TY-5