GW1-2021-01827_Well Construction - GW1_20210503

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Well Contractor Name1 1
3 Pi ft. TO DESC110TION
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NC Well Contractor Certification Number to AY X 3 2021
IS.OUTER CASWGfor multi-cased Wells)PLI, R(SifappIiV1e'TRIM,
YADKIN WELL COMPANY,INC. information Processing U ROM ft. TO DUAIIEft. :TER in. T.RIAL
Company Name EMIR Senon
2.Well Construction Permit#: "7/41 16.INNER CASING OR TUBING(geother a]closed-loo UA
L FROM TO Di"MITER1 TEUCIC�NESSW MAT-rRIAL in & ?
List all applicable well construction permits(4 e.UIC,County,Slate, Variance,etc-.) ft. q ft. ifna il in.
'n
3.WeI3 Use(checic wcl.J use):
Water Supply Well: 17.SCRE 72 N
FROT1.1 TO DIVU-JETER SLOT SIZE TUICIMT-ITS�S P.1ATEPLAL
0Agricu Itural OMunicipal/Public
DGeothermal(Heating/Cooling Supply) I Residential Water Supply(single)
DIndustrial/Commercial DResidential Water Supply(shared) in.
DIrrigation 1 13.GROUT
Non-Water Supply Well: OWells>100,000 GPD JrF',:0r%1 ,. ITO fit:
CIMTEiEUL EMPLACEr-E-rITP!Ci-BODa,tIJ,.IOUPIT
DMonitorin,a DRecovery ft- jr7 f t Pell�
Injection Well: - 2 77 ft- Or n&id t
DAquifier Recharge OGroundwater RemediatioD ft. ft.
19.SA11ID/G-PUIVEL FACIC(if applicable)DAquifer Storage and Recovery OMinity Barrier FROM TO MATERIAL PUPLA CEAUTMT ATEPT HOD
13Aquifer Test OStormwater Drainage ft• fL
DExperimental Technology OSubsidence Control F ft. ft. C-5
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecesswy) e
DGeothermal MeatinglCooling Return) 0 Other(explain under#21 Remarks) FROR" TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
ft.
4.Date Well(s)Completed: Well ED# 44 o-zz,-Y ft.
Sa.Well Location: Phone # 3 1.,
.41,6,0Ac ry fit. /K f_4
Facility/Owner Name Facility ID#(if applicablei',, 70 ft- C2 ft- Sol,/
00 32.2 t. ft. ft.
-&, (a. �7 102 M'd "5/_C 1!c
Physical Address,City,and Zip r ft. ft. i
9_ __ I
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: VA I A 0 P Col r Of 1A (b
(if well field,one lattlong is sufficient) 22.Certification:
4 1,P N IF 1 0 G
WYnJa )5'4
6.Is(are)the weU(s): ermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certt(y that the well(q)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ONO 15A NCAC 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 ofthe 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 I GW-I . needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL,INSTRUCTIONS9.Total well depth below land surface: 1402\
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)-(ft-) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form; to Division of Water Resources (DWR),
(ft.)If water level is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 13 24b.For Injection Wells:Copy to.6'WR,Ur.iderground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method, AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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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(9pm) Method of test: loci k,
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED- -3
CVISITED BY:
Form OW-1 N Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2019 A
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