GW1-2021-01853_Well Construction - GW1_20210503

Jr I I-,1
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14.WATER ZONT"
rROT11 TO DESCMPTIOU i
V1ell Contractor me
4-lil't- 1 &5-ft. 'a dp,,", !
57 re ft. �- " 11,
NC Well Contractor Certification Number 15,OUTER CASING for multi-cos wills)OR LINER(if zpplicable)
YADKIN WELL COMPANY,INC. FROM I To DIAMETER
ft. I ft. ' in.
Company Name D"%(L 7373 6 7rO 16.INNER CASING OR TUBING(eeothermal closed-loop)­
FROM TO DIAMETER THICK L
2.Well Construction Permit#-
List all applicable well construction Pei-wits(1-c.UIC,County,State,VMIOMC,etc.) 60A s"'o' SOR-1c. PU
3.W ei I IJ 5 e(C 3-i e C%I've J 1.0 se): ft. tr. in.
17,SCP2EN
Vilmev S"p9l, MIP'll: FROV, TI-1 C:L.zq S TIIC E�s
oAg,nruliuril olvfunicipal/Publir
00ecitliennal(Heating/Cooling Supply) [Residential Water Supply(single)
N
01ndustrial,(Commercial oResidential Water Supply(shared) 13.GROUT
oirrigation DWells> 100,000 GPD FrOM TO BLAT2RLAL EPIFL�',CUIENT FUETROD-I-ANOUPIT
'Non-Wn"er Slip-ply Well: 1-?en-Lko3 po 0 1/4e-/,
oMonitoring EIRecovery
C/ S')Q r P4J,`h?,ee1
Jection Well: ft.
oAquifer Recharge oGroundwater Remediation 19.SAVD/GRA'VEL PACI (if tipplicnii)e)
OAquifer Storage and Recovery oSalinity Barrier FROM TO KATERIAL I EMPLACEMENT ME-iHOD
DAquifer Test oStormwater Drainage ft. I ft.
DExperimental Technology oSubsidence Control ft. ft.
0Gcothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soil/rock typr,grain size,etc.)
DGeothermal(Heating/Cooling Return) 00ther("plain under#21 Remarks)- 0 v ft. ft.y, 0 AL
4.Date Well(s)Completed: Well m# A ho -1-7.3 T1, ft- q&T, ft-
5a.Well Location: Phone #2A3-,W17 IF ft' I/""'. t774;'l X"e"' a"t"-q'e
��- ;,(0,0% M� !7--4�e-a n
Facility/Owner Name Facility E1)#(if applicable) ft. ft.
ft
Physical Address,City,and Zip AY X
21.REAIARKS
Jr.�0rV1.1.3tiOn roe'
County Parcel Identification No.(PIN) anup Pec.41013
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
Xzr C
T-0 N
WrdV i
6.Is(are)the well(s): Bfermanent or OTemporary Si of`Ce dwelt Contractor Date
By signing thisform,I hereby certify that the well(s)was(vere)constructed in accordance with
7.is this a repair to an existing well: DYes or &�Vl 15A XCAC 02C.0100 or 15A NCAC 02C.0200 wen Construction Standards and that a copy
y'this is aieriair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell owner.
repair under 921 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
construction,only 1 GW-I is needed. Indicate TOTAL NW113ER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:. 24.supmmAL mmucrj6m
9.Total well depth below land surface: Submit this GW-1 within 30 day's of well completion per the following:
For multiple wells list all depths V'&fferent(example-3@200'grid 2@1001 24a. For All Wells: Original fIrin' to Division of Water Resources (DWR),
10.Static water level below top of casing: 95- Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+" i
Bit Off: 060 24b.For Injection Wells:Copy!1o,DW1?,'Underground Injection Control(rUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 21699-1636
AIR ROTARY
12.Well construction method: 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 ofthe county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing
over 100,000 GPD-Copy to DWR,CCPCUA
TP-rograrn,1611 MSC,Raleigh,WC 27699-1611
13a.Yield(gpm) Method of test: Perm
%HTH DATE SITE VISITED:
13b.Disinfection type: 70 Amount: Oz
VISITED BY: Ow J
I
Form UW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018