GW1-2021-00970_Well Construction - GW1_20210415

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NC Well Contractor Certification Number n 1 5 15.OUTER CASIi'(G(for multi-cas lit OR LINER(if applicable)
YADKIN WELL COMPANY,INC. H 1 FRor.I I TO I TIUCfCNFsS MATERIAL
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Company Name 1 p1 �S£r�i0(1 16.l NNER CASING OR TUEIPIG([eotber©al closed-loop)
2.Well Construction Per_,lit#° ;3 FROM To DIAMETER IT3ICICPIESS nI+TEF3AL
List all applicable hell construction permits(i.e.UiC.County,State,Pariance,etc) 4 ft• ?51 f.° C°' ,S0 R XL
.,%Veil ljs Pljec."i ,_l:- )° f#. ✓ f'd. Jon. ^
❑.4 Gr 7(;ul+li rfli ❑I�Nlttlipril�al�tlI—
❑Geotliert gal(Heating/Cooling Supph ) 111Yf_esidential GNater Supply(single) ,n• f
❑Industrial/Cotnniereial ❑Residential"Water Supply(shared) I.s ,CR1,aNT
❑irrigation t is ON TO n I Ct:T=f?L`., 1 EFH;.ACIE SNIT NFTEID `_n�_IDWIT
❑i� .s> 1 C0.000 GPy
i',ro�_grinn S"IP:13:e;, s'e'•J: el1
-- — D I 3 t, (3�n-L I �a we, _
❑1Vlonitoring ❑Recovery ft. 3d ft /3e,-S/u �/ r/
T!3J ii4inWell:--
;;. ft.
❑Aquifer Recharge ❑Ground water Rernediation
19.SAP,eDIGRAY L PACK-(if applirnbie)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To HATERVAL ERIP ACEP.IENT i ETEOD
❑Aquifer Test ❑Stormwater Drainage it. I ft.
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil rack e,grain size,etc.)
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) N• ft. /� ' �J1�4
4.Date Well(s)Completed: 4Ll't'V Well ID# Ao^ 3 I ft. 4 S• ft. /mod ie4l nP 1-4-ie ; p
5a.Well Location: Phone # 23gi s--7 /- itot G rft° 30,3 it. /yt eel
S"- fay
ft. ft°
Facility/Oi rer Nam Facility ID#(if applicable) ft. ft.
ft. ft.
,-*11614�hysical Address,City,and Zip ft. ft.
21.REZIARIGS J _
A
County h`•- Parcel Identification No.(PIN) AU ���� �� S� �O �Y' �y �
a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
6.Is(are)the well(s): C46manent or ❑Temporary St re of Ce •ted Well tractor Date
By signing this jmin,l hereby cert�that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or do 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis is a repair fill out knallm well consnvctiar information and explain the nata-e of the ojthis retard has been provided to the hell owner.
repair under#21 remarks section o-on the back ojthis form.
23.Site diagram or additional well details:
8.For Geoprobe/1DPT 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 G-I is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
7 a
9.Total well depth below land surface: 303 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For nnudliple wells list all depths ifdifferent(example-3 t@200'and 2Q100')
l O • 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijivater level is above casing,use"+/" '
(�s Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in) Program,1636 MSC,Raleigh,NC 27699-1636
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 of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingfover 100,000 GPID: Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test: 1
a DATE SITE VISITED: �`2 2—Z,
13b.Disinfection type: 70/a HTH Amount: �^�' OZ 6
Pr i� VISITED BY: hIII
Form GW-1 North Carolina Department ofEnvuonmental Quality-Division of Water Ijesources t Revisu d 6-6-2018
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