GW1-2021-00975_Well Construction - GW1_20210415

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.J,0 1°' I is� ` - 14.WATER ZOP IES
IROAI TO DESCRIPTION
Well Contractor N�P e� �"i�£t. / O £t. V-�/ea S,
J /7 r� �}n v ft. to ft. /� t�NC Well Contractor Certification Number �i r e') LU21 15.OUTER CASING for multi-cased`wells)OR LridER(if a plicable
YADKIN WELL COMPANY,INC. —FROM TO DIAMETER THICKNESS MATERIAL
DCn°"r's�,�llTf�Url11
Company Name I t r
J��� .,{,011 1G.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#:_ 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constriction permits(i.e.UIG County,State, Variance,etc.) ft. / ft. �,�in. sA�Z 8 I✓�
3.Well Use(check weal use): ` ft. �v £t. in.
17.SCREEN �•'- t
Water Supply Well: FRO5I TO r DWMETER:I SLOTSIZE I THICKNESS I 1'.IMIlL L
OAgricultural OMunicipal/Public It, ft, in.
OGeothenual(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial (!Residential
Water Supply(shared) 18 GROUP I
❑Irrigation ❑Wells>100,000 GPD rRONI TO MATERIAL ERIPL ACEMENT METHOD L ARIOUNT
Non-Water Supply Well: ft. q ft. tsl e6'VJ soodW
OMonitoring ❑Recovery ft. ft. S/
Injection Well:
ft. ft. '.
OAquifer Recharge ❑Groundwater Remediation
19.S�IVI1/GRAVEL EACT3:(if applicable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACr ENT n.IETHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimentai Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothennal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /t� ft s� , ft FROM TO DESCRIP,TION Rotor,hardness,soil/rock aein size,etc.
!
4.Date NI/ell(s)Completed: 3-1 -aq Well IID# /4 1g0—A gala £t. 3'9p ft. 1AW—oI ,509 ;+ S dk
Sa.Well Location: ]Phone #4f 9=�3 3�� �� 8�r£t. 6->� ft' X4r&5'0f' oeid<q 04-
G'<'t kk 14, ft. 11q05, ad jA4v
Facility/Owner Name Facility ID#(if applicable) ft. ft.
� // ft. ft.
n E If t%rd,* ? ft. ft.
Physical Address,City,and Zip
11 I 21.RENIARKS
County<� �l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.Certification'
31� fJ13 N
6.Is(are)the well(s): Oermanent or ❑'Temporary PKe ofCerti&4 Well Contractor i Date
By signing this fawn,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or Imo 15A NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information Aexplatn 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 welt 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: d 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 ZP®5— (ft.)
For multiple wells list all depths ifdierent(example-3 00'and 2@100) Submit this GW-1 within 30 days kof: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: 7•Q8 9' 24b.For Igiection Wells:COPY to DWR,Underground Injection Control(TUC)
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) �y Method of test: /
I36.Disinfection type: 70%HTH Amount: �14 OZ DATE SITE VISITED: t l 4 Q 0" �
4E /t? gA irsvt &i 4"7 "mod�- VISITED BY: t.l�� Y