GW1-2021-01891_Well Construction - GW1_20210503

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Well Contractor Name ocit. i1a I ft.. a.
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cos 4if ells)OR LINER(if applicable)
FROM TO DLAAECTER THICICNEis I MATERIAL YADKIN WELL COMPANY,INC. in.
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Company Name 16.INNER CASING OR TUBING othermal dosed-loop)
2.Well Construction Permit#: 35j?,6_V FROM TO DIAMETER I TmuNESS
a-iance,etc.) ([Ax Vc-
List all applicable well construction permits(i.e.UIC,County,State,V i ft.
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ft. lt in.
3.Well Use(check well use):
17.SCREZ-P1
Water Supply Well: Mori TO D71_1fdETEP, SLOT SIZE T i
DAgricultural DMunicipaUPublic ft. ft. in. I
DGeothermal(Heating/Cooling Supply) DResidendal Water Supply(single) it. ft.
01ndustrial/Commercial NZesidential Water Supply(shared) 13.GROUT
DIrrigation DWells>100,000 GPD rRop.1 TO UATERIAL Er,LPLACEr.-E,:i'ITP.,T—,--TBOD&AfrIOTJPIT
Non-Water Supply Well: 0 it. ft. &n_k4J4__e- t'
DMonitoring DRecovery CY
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Injection Well: ft.
oAquifer Recharge OGroundwater Remediatioif
19.SAND/GRAVEL PACI<_Off applicable)
0Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL-I A iqTr, TE1_
OAquifer Test DStormwater Drainage ft ft.
oExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(Efeating/Cooling Retain) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillnck type ain siz etc.)
0 ft. S_ ft. •
4.Date Wells)Completed: ft. ft.
I)J. Well ED# 'IL �eW f),-X 1 49,11-)5,
5a.Well Location: Phone , #
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Facility/Owner Name Facility MX(ifapplicable) ft
ft.
Physical Address,City,and Zip ft. a-
A21.REMARKS
County Parcel Identification No.(PIN) 1I.Jormation Processing Unit
DWR Secnon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
N W 9% ,
,4AZ&x/
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6.Is(are)the well(s):APermanent or oTemporary Signature o Certified Well Contractor Date
By signing thisform,Ihereby certify that the well(s),was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or )bNo ISANCACO2C.0100orl5ANCACO2C.0200 Well Construction Standards and that a copy
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 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages ifnecess.ary-
drilled:_ I % 24.SUBMITTAL INSTRUCTIONS9.Total well depth bellow land surface: 51WL
--(ft') Submit this GW-I within 30 days,ofwell completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1 OOD
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: I S0 (ft-) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
4/1 Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
1.1.,Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
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
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) 130 Method of test: ? —
70%HTH Oz DATE SITE VISITED: 3-Q
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revise 6-6-2018