GW1-2021-00296_Well Construction - GW1_20211213

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' '+Cd31�1�1 NC1T�C�1�Lam+CORD(GW-13 For Internal Use Only:
1.well Contractor information:
14.WATER ZONES I
Well Co'ntractor'N a FROM TO.pr DESC TION 1
NC Well Conhactor Certification Number
15.OUTER CASING for niulfi-cased wells ORLINER >f a licable
YADKIN WELL COMPANY,INC. FROM TO DIAMETER TfficKNns MATERIAL
ft. ft in.
Company Name
16.INIIVER CASING OR TUBING(I geothermal dosed too
AA 2 .+ FROM TO DIAMETER TEacimFss MATERIAL.
2.Well Construction Permit#:A 1330 0)�
Lisf all applicable well construction permits(i.r-UIC,County,State,Yariance,etc) R R 2 rn S •1 vc,
' ft ft. in.
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THIC(OYEss MATERIAL
❑Agricultural ❑Mumcipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) 11ft/sidential Water Supply(single) ft. in.
OlndustriaUCommercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATEIUAL En'IPrACEMENTML+THOD&AMOUNT
Non-Water Supply Well: O ft. 6 ft -ekas no t-L-o*
❑Monitoring ❑Recovery iL /3 ft SI t;e .291ApTer
Injection Well: ft ft.
❑Aquifer Recharge []Groundwater Remediation
19.SANDIGRAYEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft S-
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothemlal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheets ifnecessa
❑Geothermal(Heating/Cooling Rehm) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,h¢rdaess,mil/rock im abbe,etc S
4.Date Well(s)Completed: 47-1&--'V( Well ID#tf j 7 a •3• �,3 ft a07• fL miwsiwy C-X
Sa.Well Location, Phone # ft fL
CPaw ft ft Face' /Owner Name/` Facilil/eyM#(ifappliccable) ft. it t 1;
�6�Y/ItC)48Ys' Zwiey l �is(Jt`C� 11011 ft. ft 1.r 1
Physical Address,City,Hud Zap ft ft. f
yS _ 21.REAL RKS _r, ,`!
Cou* Parcel Iden1rEcatim No.ami) i
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe�ll field,one lat/loagis sufficient) 22.Certification:
34
® L�®Y -72- N 9-®� 7�1w / W ri, t/l l I
6.Is(are)the well(s): 6fermanent or ❑Temporary iiiioggature oLVrffied Well Contractor Date
By signing thisform,I hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lla!`!o ISA NCAC 02C.0100 or IAA NCAC 02C.0200 Wel!Construction Standards and that a copy
If this is a repair,fdl out!mown well construction information and explain the nature of the of this record has been provided to the well owner. 4
repair render{t21 remarks section or on the back of ihisfann. 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 conshnction iufb
construction,only 1 GW�l is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).,You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths Ifdifferent(example-3(a3200'and 2®1001 A
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 \1C
Ifwater level is above casing,use"+" F
11.Borehole diameter CI (�) Bit Off: •o o 24b.For Infection Wells: Copy to DWI;,Underground Injection Control(IUC) `
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
(Le.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
QQ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 7S t Method oftest: • /�O � - `'�
13b.Disinfection type: Amount:
70%HTH Z DATE SITE VISITED: �O /_ - Z- tD'pe
�•� r �Aa
VISITED BY: DOB
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