GW1-2021-05470_Well Construction - GW1_20210722

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3ev'r-1 Wot4-k%!2) rk'A'HR ZO-i411-
MON TO DESCRIT7100 I
Well Z.rit,.�tar NameA X7 3ft. fL
RC Well Contractor Certification Number
15.OUTER CASING for I lls)rB.L if applicable
TE[[MR r
YADKIN WELL COMPANY,INC. FROM I TO 1_12925 cased wells
MATERIAL
Company Name
16.INNER CASING OR TUBING(g6otherwal'dosed-loop)
2.Well Construction Permit c9 7/Z Al' FROM TO DIAMETER TMCENESS MATERIAL
List all applicable well construction permits(ke.UIC,County,State, Variance,etc) 4 t,t :in-
I evc
.
3.Well Use(Che&We)!Use): ft. ft in.
Water Supply Well:
MOM TO DIAMETER' SLOT SIZE U-10crilKSS HATrLRIAL
DAgricultural oMunicipal/Public ft. ft, in.. I
DGeothermal(Heating/Cool ing Supply) Xesiden'tial Water Supply(single) in.
ft,
01ndustrial/Commercial DResidential Water Supply(shared) Mt.GROUT
DIrrigation I DWells>100,000 GPD FrOPQ I TO MATERIAL EMPLACEP.104T PaTETHOD&AJAOUPIT
Non-Water Supply Well: U ft. ft.
We fto pyirej 4
io,I!%S
0monitoring ORecovery b
Injection Well: 3 f,- 31 ft. &J1C?- (:!-;-OA pvmml
ft. ft.
0Aquifer Recharge oGroundwater Remediation
19.SA q D/GRAVE PACK(if applic3ble)
OAquifer Storage andlRecovery DSalinity Barrier •FROM TO MATERIAL EDUPLACEMENT METHOD
DAquifer Test OStormwater Drainage J
OExperimental Technology OSubsidence Control ft. ft.
I DGeothermal(Closed Loop) bTracer 20.DRILLING LOG(attach additional sheets if necessary)
.
I FROM TO DESCRIPTION(color,hardness,soiftdc typc in size,etc.)
OCTeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
ft.4.Date Well(s)Como I leted: Well ED# AJ 99.!!Z f/ -7 S ft' 3p.) ft 6
5a.Well Location: Phone
If - ft. ft.
1w
Facility/Owner Name Facility H)#(if applicable)
7 No A I" R40
Physical Address,City,andlip ft. ft.
21.RE N1ARKS
County Parcel Identificatio'n No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W
gniff e M ell Contractor Date
Is(are)the well(s) ermanent or OTemporary Si lure offarti
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existingMo 15ANCAC 02C.0100 or 15A NC,4C 02C.0200 Well Construction Standards and that a copy
well: OYes or 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#21 remarks�sectlon or on the back of this form. 23.Site diagram or additional wellAetails:
I 8.For Geoprobe/DYi or Closed-toop Geothermal Wells havingthe same You may use the back of this page to provide additional well construction info
_J
,construction,only I GW-1 is needl. 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: 3 7Submit this GW-1 within 30 da 6.fwell completion per the followin
Formultiple wells fist all depths ifibffereni(example-3@200'and2@100D ys g:
24a. For All Wells: Original forni, to Division of Water Resources (DWR).
10.Static water level below top of casing: 50 (ft) Information Processing Unit;1617 MSC Raleigh,NC 27699-1617
Jfwater level is above casing,use
Bit Off:110-7al 24b.For Injection Wells:Copy to_DWR,Underground Injection.Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 2160-1636
12.Well constructionlinethod: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,c&ci push,etc.) Ir county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm) Method of test:
�0%HTH L4 51TED-
13b.Disinfection type "Amount: DATE SITE VI,' 7
VISITED BY. 6/00
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201
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'PRICE '