GW1-2021-01470_Well Construction - GW1_20210305

1M7)EL L CONSTRUCTION 'H tC )RD I(cGW-1l'
1-Well Contractor Fn=or-mation:
%
Well CoutractorName
TC Well Contractor Certificationhumber •.✓ .-`1
'15.Grp_' ?':nv f;d' i- c :=tt-)�rZLLIEL�(-a plicz}ale' - ...
Well Yadkin Company n _,_rt_,,:�-_ xarcT��rss
Company Name
.16:51; i•_'�r_�91'1�_b T ti�T1' tr �e-'"'^pclosed-laa - - vn, :' -
2.vtiteL Construction Permir#:ji/U.j bAT= -C)9uD o ;, , ERarre I _n I __ n_. TMMOT+ss
List flit 0pplicob/eWell ants(( COTIPerntifs(i.e•UIC,County,State,Variance,etc.) � I z3-o - I ,�Q!�CZI - I 5 0 a 11 F Lid
3.Well Use(check well use): I I I
Water Supply well: "_+7.SC -
Tt?i:4 _-- I SLOTS ss
Agricultural 014unicipal/Public
!=GGeothermal(Heating/Cooling Supply) Residential water Supply(sing_lC)
IndustriaVCommercial I
�[(IResidentia]Water Supply(shared)
NI:Irrigation =title: ! Tr, -- r
S11PL4�iir_]tiT H2u2�rJ± __ _ __
Tdon-water Supply Well: r
CMccovely InjectionFltell:
[Aquifer Recharge ©I Groundwater Remediation
Aquifer Storage and Recovery [Salinity Barrier - -__ T. - -
_Aquifer Test' IStormwater Drainage I i =-
_Experimental Technology OSubsidence,Contra] ! =:= I -
C Geothermal(Closed Loop) Tracer ?o._"P+,;..,;,•?� :saE:2:;; ,a�isiAesifne�sszi._. _ -
W'OlA 1 T !__•TGr-y,_M•L' 4(c01.,_b rdne<s.:oih-ocktyp
Ce main Geothermal(Heating/CoolingRetam) OF Other(explain under#22 Remarks) _ --
9.Date Well(s)Completed: B �1 �.D Y1rell ID# <
Sa.Well Location: Phone number-
00 An &y lam ell'
-
Tacility/Divner 7VaIDe Facility M4(if applicablo)
Physical Address,Cy, d Zip
Ljit
^7-
county Parcel Identification No,(PIN) --- -
5b.Latitude and longitude in degrees/minutes/seconds or decimal deg?ees:
(ifwrll field,one latdongis r*fnitnt) ---
71 0 ¢
6.Is(are)the well(s)mpermanent or [3Temporarp Date
b},sr��ing dzis_"om-, 1 %(s)was(were)const)ected;,,ec.c:
7.Is this a repair to an erdsting well: ElIZIes or Mo hdtli 15A htCJC 02C 0)00 c7=_. ;VC.°C 02C.0200 Well Cars(ructiau Stawer -,s c-
If this is o repair,jSAoutlma>r,)n5,41 construction;(formotion mid 41ain the natwe af(bE colt•c;'s is;eccrd cs c__ _ :r• :i=:= •ett,'r.'oianer,
repair under m21 renmrkr section or mt the back o}'lhis form.
S.For C-eoprobe/DFT or Closed-Loop Geothermal Wells having the same ='ou Miry'CUE Lle nacir LOT'Lh,; ;;arc tt provide additions Fell site detalc a
construction,only 1 GW-1 is needed. Indicate TOTALNUNII3ER ofw ells construc5on d5uis. -o�rr:-:•i'Cr_t1 cr additional pzges ifnecessary.
drilled:
9.Total wa depth below land surface:_ -m )
;ta r,{o ,�i >;ibrL,t r,1s _� ,2� 30 days of complena_hiple}reDslistalldepihs ifdiffetntf(erample-3@200'ond2tt n0�
For mu cpns o GD. i[: rie'piio;:,:,-,r
10.Static water level below top of casing. 5_()1 (in) r_-NI` ;L, Fri q-r F_i:,. L=c-=, �ormatIon Processing 67n ;
7fv'oterlevel is abate casing,vie+ ei_`i P•;i,•:f_ =_c::y c _-.?sleigh,NC 27699-1617
IL Borehole diameter: (in.) ppBit off &® 3 tb I,Q_f 'ir c oo ti%ite s; r' uido_io sending the form to the addrEs.
12.Well construction method: Ae, f o4-t;a. above, also submit eae cop.; i!1 s Ica- v ifhin 30 days of mtopletio. _2.
CCl]SS�tCUOr�t�J tLc f01!C'�6 7E(Le.auger.-tam cable,d rertpusl;eta)
FOR WATER SUPPLY WELLS ONLY- 1 �•:.sc.c •_i ,_-,. - Lnd ln'e^ao'^ p-cg:•_
?: I i e . 1?.z_leigh;NC 9 7 699-163 6of
P
13a.Yield(gpm) Method of test: �>b° 24e, o yNate_ ,_ I,i .L_«o_ its: In addiiion to sendme LC_r'O_,_
CUPS �9 p the addrees(Cs} FhoV e: `i.=_o cui c __E copy of this four •tadthin 30 day:
13b.Disinfection type: HTH Amount- r� D (� completion o_i,v_'il or t:n=-.:,;,i;c, e count} health department of the
where COu3huCtr-C 79
Folm GW-1 North Carolina Depm-6ment ofEm'uo*meaW QuaLr_,'-D,'vi-:c c •ues g t
I3i e$itF_1 ViSZtE�d Q Q m I_-sji
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BUILDERS NAPAE- k-j ADDRESS: Ace-
OFFICE
CELL# 3L
COMPLETE IF INVOICE IS BILLED TO
4/M Contractor
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1101
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YA K J COUNTY
°F"' `•"`:'"" YADKIN COUNTY ENVIRONMENTAL HEALTH,
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WELL LOCATION
14-062-JWCo.
APPLICANT/ _ p
OWNER ®t / .��; �� - PERhAIT � `� _r?l,%.� .- e'7 ;z.1TE:
ADDRESS '
WELL INFO
fW WELL ❑REPLACEMENT WELL � �fLL FOR SINGLE RESIDENCE-
❑WELL FOR 2 OR MORE RESIDENCES ❑PRIVATE WELL ❑PUE',LIC WELL
(Not to Scale)
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a'�c'�r��.� etc' Cam'-.�.��Cd [�ic�C�i�•-� i.9tA4✓` l.�•
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Comments:
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Name,REHS#
I Authorized State Agent
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