GW1-2021-01097_Well Construction - GW1_20210305

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Well Contractor N
45 ft. J v ft.
NC Well Contractor Certification Number r`
"�;� <15:OUTER CASING(for riulti-cased wells),OR LINER(if a licable
YADKIN WELL COMPANY,INC. ?.• ; FROM To DUMETER' TffiCxivEss IYIATERIAL
q�. `� !in.
Company Name 16.INNER CASING OR TUBING pke6thermat closed-loop)
2.Well Construction Permit# (2 7 FROM TO DIAMETER THICI(iYESS MATERIAL
List all applicable well construction permits(i.e. C,County,State,Variance,etc.) +� ft. � It. � !o ;in-
ft. '1 in.
3.Wela Use(cl�ecL weir,lase):
17.SCREEN
Water Supply WeN: Water
TO ya'v u.i R L OT S;ZE TEK3"aES1- { 41A_,EZi+-!
E]Agricultural ❑Nlunicipailftblic
❑Geothermal(Heating/Cooling Supply) Aesidential\muter Supply(single) t+. I f?•
❑Industrial/Commercial ❑Residential Water Supply(shared) yg GROdJT f
irrigation ❑Wells>100,000 GPD FROnr TO B£sTEP AL ra'Ii,t+v.,�aa_t;a MET O_��:AMO!ia±
Non""later Supply Well: 4 fit. 3 ft. de Plari Numk S
❑Monitoring ❑Recovery 3 ft. a [ ft. &tGk`iPodF PtINn 3`��
injection Well: ft. ft.
❑A uifer Recharge ❑Groundwater Remediation
q d 19.SAND/GRAVEL 1D/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMTO ]YL TERIAL ENaPLACERIENTRiETHOD
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUrock e,grain size,
❑Geothermal(lIeating/Cooling Return) ❑Other(explain under#/ Q
2�1 Remarks)_ ft ft
v SOr
4.Date Well(s)Completed: l �` Well ID# d 7 y A 3 7/ '70 ft' �.2 ft• GrO/1 t
/ 7
5a.Well Location:
,�y r PhOn
t-A,
Facility applicable)
ft. ft. �•
Facility/OwnerNaQm ty ID#(�®e if
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 well field,one lat/long is sufficient) 22.Certification:
N 81. 0LA-11;)9 W
Signat re of Ce
6.Is(are)the well(s): ermanent or ❑Temporary
ied Well Contractor Date
By signing thisform,I hereby certify that the'well(s)was(were)conshucted in accordance with
7.Is this a repair to an existing well: ❑Yes or XlNo I5A 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#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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
f
drilled: 1' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3XI (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: $ (ft•) Informatior Processing Unit 1617 MSC,Raleigh,NC 27699-1617 _
If water level is above casing,use"+" ! 'r
Bit Off: a o 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) (J
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 217699-1636
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
LIX
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,600 GPD: Copy to DWR,CCPCUA
[� I Permit Program,1611 MSC,-Raleigh,NC 27699-1611
13a.Yield(gpm) is,
Method of test: At I k- ' a
o DATE SITE VISITED: /4'd `!G7 11
13b.Disinfection type: 70/o HTH Amount: OZ A
VISITED BY:
Form GW-1 Nardi Carolina Department of Environmental Quality-Division of Water Resources i t r _ Revised 6-6-2018