GW1-2021-00977_Well Construction - GW1_20210415

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NC Well Contractor Certification Number APR 1 J 2021 15.OUTER CASP[C-(for multi-cased :'ells)OR UPTE1; r,lieabla)
YADKIN WELL COMPANY,INC. rRo74I To DIPJ'iETER T3ICInlESs I14ATEPUL
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Company Name �: L.,r.� ,
�., t,0i1 16.1NPIE p u-,CASG OR TUBNIG(, n3 eotheral closed-too.)
2.Well Construction Permit#:_ (�F (, rroM TO DP-METER THICKNESS MATERIAL
List all applicable well construction permits t!e.UIC,County,State, ilarionce,etc.) ft- JL V ft- &. t /0 0 � V
3.WeN Use(cheese well L;m): ft. ft, I in. p
Water, Saappiy FVe11: --- 19.L-a-ai�?l i - - ?�
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❑Agricultural ❑Municipal/Public is I ft, I I u - I _
❑Geothermai(-t+eating/CooLng Supply) Xesidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation 0Wells>100,000GPD F-EtN:1 To
Non-Water SupplylVell: � it, 9 1 ft. 1 em Ifei ,, Q�
❑Monitoring ❑Recovery
Injec'sioa Weak f ,
ft. fr. l
❑Aquifer Recharge ❑Ground�a�ater Remediation
19.JAI ov'Ge-.s nrE L p A fiat(iti
❑Aquifer Storage and Recovery ❑Salinity Barrier FFficl TI? I H,A71 ErL_1L E PUPLA CE P;-P.iT t,.-TENDD y�
❑Aquifer Test ❑Stomiwater Drainage ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLITIG LOG(attach additional sheets if necessary)
FROM To DESCRIPTION color,hardness,soillrocic e, rain size,etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Oft. 1;z-' ft. 5 P
4.Date Well(s)Completed: e'�'U Well Id2D#j/ Q/[�/p` C�>//ry C'2 ft. /� - it. m� -jaw-,
5a.Well Location: Phone
J7W�(V! 3 1� C ft. ft. l�
ft. ft.
Facility/Owner Nam { Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip ft. ft.
f0 a 21.REMARKS
County Parcel Identification No.(PIN) " P, _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: dv QC '
(if well field,oneel/lat/long is sufficient) 22.Certification: e
6.Is(are)the well(s):I/1Permanent or ❑Temporary
Si of Ce Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (ilNo 15ANCAC 02C.0100 or 15A NCAC 02C.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 ofthis record has been provided to the we11 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 if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C�� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@206'and 2Q100D
�� • 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
If water level is above casing,use
11.Borehole diameter: (in.)
Bit Off: . C ® 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
Ltd
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) sl®® Method of test: riG I
13b.Disinfection type: 70%HTH Amount: �j OZ DATE SITE VISITED:
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ki ax e- >�s kl y e-w ®yt ��lh a-� VISITED BY: V 6
Form GW-1 North Carolina De artnent of Environmental Quality-Division of Water Resources Revised 6-6-2018
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