GW1-2021-01859_Well Construction - GW1_20210503

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1';rell Contractor Name ft. L�)a it• 7 r. �f 176Pe"
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased cells)OR LIDTER(if applicable)
YADKIN WELL COMPANY,INC. FROM TO DLIMETER TEUCKNEss MAMMAL
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Company Name ``'' �/ 16.INNE,R CASING OR TUBING( eother-Lot closed-loop)
?.Well CO?st3'+�ctioa i'C�r�Ii`r#• .21 0.2 W Ot-t�. -�(�TZ T q pFI3OM TO DIAMETER TEIICI4'IESS h-IATI:Pr�L
7Z yr in. �sa y
List al!applicable well construction permits(7.e.(IIC,Counrp,Stale, G`oriance,elc. ft. ft.
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-72
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❑LeOtnei 3]31(1�''fitt ilg!'_0011?lg SLpnl}+) - ❑I'BSL�lent?fil wade?'SLplil}'
❑lndustria':/�'ouunercial ❑kesidentiai iYater Supply(shared) 10.CROTLIT
❑i.Vells> 100.000 GPD FROM � TO
I r:?=;T=r•I?L R3r L.-': Ei t idT i:3= n_.`:`JsI?ti1T
❑Ir rtgatto3l _ `
1T4 1_ --'-- -- .13Sf; I �� ;r. P046fid
❑Recover r �.� ?s• O ft•
!riect.4 4 Well-, ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAPID/OFtrl':'PSI,pA ICI_jit npplicnblt)
❑Aquifer Storage and Recover; ❑Salinity Barrier FRON TO I._G% ERLkL ERIFLACEr:'3ENT`ILTE1OD
�� ❑Aquifer Test ❑Stormwater Drainage
�l Y'�j ❑Experimental Technology ❑Subsidence Control ft. ft. /
VV '` ❑Geothermal(Closed Loop) ❑Tracer 20.DRYLLING LOG(attach additional sheets if necessary)
FRom TO DESCRIPTION(color,hardness,soillrock typc,gain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o
4.Date Well(s)Completed: 3 s a 1 Well ID# A-60-3 0� ft. )?, ft.
p a ft
. a1 ft- ^�S �
5a.Well Locations: Phone # 33�- 2-3-7- 1 M
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FacilitylOwner Name Facility ID#(if applicable)
aj�t r tyT ! dsre CMt��Ut�e5 ft. ft. \'i;JOvv E
Physical Address,City,and Zip
21.RE,rvIARKS
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County un d Parcel Identification No.(PIN) (G Ido(P D r i lied A O Lf L' C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —"eft-A $,• +U
(if well field,one latllong is sufficient) 22.Certification:
6 js(are)the well(s): dermanent or ❑Temporary Signa a of Ce •fied Well Contractor Date
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By signL;g,his form,l hereby certi,that the u,ell(s)a as(ww-e)constructed in accordance a,ith
7.1s-this a repair to an existing well: ❑Yes or II<0 1 i^MCAC 02C.0106 or 15A NCAC 02C.0200 Tfrell Construction Standards and that a copy
If this is a repair-,fill out known well construction nforniation and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or an the back ojthis form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
S�9.Total well depth below land surface:
(ft") Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3ta 200'and 2Q100')
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
Jf nvoler level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off- 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) .
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
lja.Yield(gpm) ® Method of test: Q 1r' 1
o DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: + OZ t
VISITED BY:
Form GVrr-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2015 {�