GW1-2021-02311_Well Construction - GW1_20210722

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i
M CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
TkI-n _
14.':WAT>;R ZON1;5 -' I l ie'
FROM TO DESCRnTION ,
Well Contractor Name
ft. ft.
4 (00 GPI+
arc Sa A ft. ft. t
NC Well Contractor Certification Number 15.OUTER CASING foc multi-d ediw•ills' R'L-YNU-'if a"licatile
YADKIN WELL COMPANY,INC. FROM To DIAMETER OTHICI MESS MATERIAL
ft. ft. in•
Company Name 16.INNER CASING OR TUBING: eotherioal closed=ldo
2.Well Construction Permit#:W art "
Q(� f 2-0 21' FROM TO DIAMETER TEXIINESS • MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +f ft. / Ft. G to SDQ'� �V
ft. in•
3.Well Use(check well use): _
17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ nicipal/Public ft. ft. i in.
� �
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑IIrI ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. C lu PadrA 3 p
❑Monitoring ❑Recovery t3 ft. ft' QJlC,k 6ro
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAv.EJ;PACK if.a`'"tichble''-'' '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.:DRILLING`LOG atGich ad'difional`slieets;if necessti
FROM TO DESCRIPTION color,hnrdness,so,Vmdc e, ram siae etc.
❑Geothermal(I-Ieating/Cooling Return) ❑Other(explain under#21 Remarks) �-•�� CC--
o
� AA d ft. .7 J fr. soil
l
4.Date Well(s)Completed: G Well ID# /- ATZ) � 7� 5_ ft. a7 ft. 6n4 i
ir
� -1
Sa.Well Location: Phone # �iC 20 P 8 3� -
ft.
t1W.K6. Facciilliity/Owner(�Name Facility M#(if applicable)
2 00 T 190&G 1'l J /tOCwV t7�/✓1�74vlu ft. ft
Physical Address,City,and Zip
�}'�� 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wweH field,one lat/long is sufficient) /� p 22.Certification:
-�atl O S. �� T N dJ©y T i �.� 9' W
6.Is(are)the well(s): Wermanent or ❑Temporary s Signatdre of Cerified Well Contractor Date
r I
_/ By signing this form,I hereby certh1 that the well(s)was.(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ll�l`io ° '•' 15A NCAC 02C.0100 or 15A 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 021 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 infof
construction,only 1 G -1 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: -(ft-) Submit this GW-1 within 30 days of well completion per the following
For multiple wells list all depths if different(example-3 r©200'and 2©100� s J
,^1 24a. For All Wells: Original form to Division of Water Resources
10.Static water level below top of casing: ft) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: 4, 24b.For Infection Wells: Copy;to DWR,Underground InJection Control
11.Borehole diameter: (iD) Program, 1636 MSC,Raleigh,NC 27699-1636
4 .
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) d
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producme.over'100,000 GPD:Copy to DWR'CCPCUr y
Permit Program,1611 MSC,Raleigh,NC 27699 1611
13a.Yield(gpm) �en Method of test: At C
70%HTH I OZ DATE SITE VISITED
13b.Disinfection type: Amount: r ^^
VISITED BY:
Nnrth Carolina Department of Environmental Quality;;Division of Water Resources Revised 6-6-2018