GW1-2021-01468_Well Construction - GW1_20210305

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WELL iC®NS'I RUC7EION RECORD(GW-1)- f,y: . . For Internal Use Onl-y;
1.` L11 Contractor Information: c'f.,M`5✓'
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Rd L� ,�• FROM TO DESCRiP ION
Well ContractorNam ( 'iL c`."M•� t
r Yin,
NC Well Costar con Number \\� 2
15.0OThIY'wAS-TC-formvlfi=cat"sed5 ORILVER"zfii"licaTrle;_.••''-: _.
Yadkin Well Company Znt -oryr'� .',•' FROM I TO D- Tmtss MATT aTd T.
Company Name ( S fs`� �„,5 :. :. •-
VU-5 h�P C`� 4 :x6:T1IlYtR t?53Pf�©1tTT16�T[x eotlieiinalcl�sedlau _ _.
2.Well Construction Permit#: FROM To DIAM TR TSICRNESS •MATERIAL ;
.List all opplicable well construction pararits C e.tIIC,County,State,Yeafance,etc.) ft
3.Well Use(checkwell use): EI
4rVaterSupply�Peil: 'I7.-5€?REgiT
FROM I TO DIAMC"r"ER SLOT SIZE THICMCSS MATERUIL
F Agdoultuiral nhblunicipabTublic zn
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) in.
Industr aUCommercial Residential Water Supply(shared) _` 8_- � _. ,• i -
Irrigation FROM TO 1AE4TZR1A EnxPLACEAMITMETE[OD&AMOUM
Yon Water Supply Well: &,V-ek t tba eel
DE_--Monitoring Recovery 3 7% 00, Nd14 ' Fs�
Injection Well:
ft. ft
C Aquifer Recharge OGroundwaterRemediation
AFZfA/CFiOJN E ALA sf nruable
'Aquifer Storage and Recovery �Sa111tylarrler NLOnx TO I
nxATERIti-.L E METHOD -.
W Aquifer Test CDStormwaterDrainage ft
Experimental Technology OSubsidence Control ft ft
C Geothermal(Closed Loop) OTracer kDItlI3'1NGtOG,`attacT—daitzoiiidih ets;fneccss ... ' .. .:
Geothermal(Heating/Cooling Retcus} [`0ther(explain under#21 Remarks) 11RoM To DlrsCMnOrr toloA hardnz=.smitre xty a •grain's4c at-)
4.Date Well(s)Completed: ��WeII TD# -asp'e
5a.WellLocation: Phone number
ft ft
Facility/OwnerName Faciility1D#fifapplicable) R' f
ft ft
Physical Address,City,and Tap ft rt
1- za-R>;l s.' .
County PsrcelldentificalionNo.(P1N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cifwell field,one lat/longis sufficient) 22.Cert ficaf.on:
6.Is(are)the wells)fflPermanent or OTemporar9 Si e ofCe ` d We Canuaator Date
By signing this farm,1 hereby ceri'fy that the wall(s)was(were)conspucted in accordance
7.Is this a repair to an eirisling well: MYes or 92 o with 15A NCAC 02C.0100 ar I5A JVCAG 02C-0200 Mell Constmerion Standards and that a
Ifthis is a repair,fill out mown well conshvetion information and explain the nottire of die copy ofthis record has heen provided to the well owner.
repair under 421 remarks secilon or an the back ofthisfarat.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
coDstaiction,only I GW-1 ii needed. Indicate TOTALNITIVIil3ER of wells construction deta�s. You may also attach additional pages ifnecessary-
drilled c SU.IIWFTAL TRUCTIQNS li
9.Total well depth below land surface: 24a. For All Wells: Submit this farm within 30 days of completion of well
For nulliole wells list all depths ifdrffem?1(example-3@Z0'and2 700� conslruatiou to ills folloF ing
�,�o
10.Static s,ater level below top of casing. cd�` (Yz.) Division oat Wt ater Resources,Information Processing Unit,
lfwaterlevel is above casing,use"+" �y i617 Muff Service Center,P sleigh,NC 27699-1617
11.Borehole diameter: (iu.) Bit� �?`��� 24b.For Iniection Wells: 1 addition to sending the form to the address in 24a
above,also submit one copy of this form 1.A thin 30 days of completion of well
12.Well constr'netionmethod: construction to the foIlowing:
(i-e.auger,rotary,cable,directpusb,etc.) `
Division of WaterResourees,Un�'elerground Injection Control Program.,
FOR WATER SUPPLY WELLS ONLY v 16361v1a0 SeMee Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) Method of test: 4 A�' 2t.'c.For Water Supply ck IniectionVeps: In addition to sending the form to
1d the address(es) above, also submit one copy lof thus form within 30 days of
13b.Disinfection type: NTN lamannfE completion of well construction to the county health department of the county
where constructed.
Finn GW-I North Carolina Depattmtat ofEmaironinental Quality-Division of Water Resources � Revised 2-22-2016
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u0°JKIERS NAME BUILDERS NAME.
ADDRESS- ADD S,
PHONE# / OFFICE#
CELL#
COMPLETE IF INVOICE IS BILLED TO
Contrabtor
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%10AAlN/06/2021/WED 09: 45 AM Yadkin Cty Permits W No. Jh-d4y-'/RL f. uul/uut
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YADKIN COUNTY ENVIRONMENTAL HEALTH
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WELL LOCATION
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APPNERLI "CANT/ 1`
OW "5 1� V' /-S PERMIT#wm r--of I o2o-� a)ATE:of-43�-zo 7—gDDRESS QV, A,�� Z-70 Z�
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WELL INFO
�EW WELL ❑REPLACEMENT WELL /WELI,FOR SINGLE RESIDENCE
❑WELL FOR 2 OR MORE RESIDENCES ❑PRIVATE WELL o PUBLIC WELL
(Not to Scale)
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Comments:
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Name,REHS# � � Authorized State Agent
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