GW1-2021-06270_Well Construction - GW1_20210915

--- --
FRON TO
Well Contractor Name ft.
3L)3 c 4 . 27j- 276 it.
33S ft 33L IL a,Z '
NC Well Contractor Certification Number 15.OUTER CA SRyj for multi-cased wells OR LEVER if a ticable ^�
YADKIN WELL COMPANY,INC. FROM TO DLlli�1ER T1fCIQdEMATERLAL C�
Company Name tV( VA-1 3
ey 7 T 16.IlrNM CASING OR TUBWG otbermal dosed-lo° )
2.Well Construction Permit#:_3 3 �^.Y6 FRons To DIAMETER TffiC{QVESs MATERTAT. i
List all applicable well construction permits(ce.UIC,County,State,Valiance,etc.) ( fr• 6 fr. F44 in. Pvc-
+1$-
3.Well Use(check Ivell L•ze): fr. �+ ft in.
Water Supply Well: 17.3CRE2N 1 e7111.01-i TO DIAP.'nTe.1 SLOTSIZE TnrC4t=s0 RiATEPi=1. I
❑Agricultural OMunicipaUPublic ft.
DGeothermal(Heating/Cooliug Supply) Wesidential Water Supply(single) It ft.
01ndustrial/Commercial DResidential Water Supply(shared) I.,CF10U_f
DIrrigation ❑Wells>100,000 GPD rpord TO P&A TERITI v_r:�LACEr.ENT r.OTgon 6 ATAOUNr C
Non-Water Supply Well: 0 tt' .3 ft „f�. (a/ArI ?
DMonitoring ORecovery S EL a s ft f!
Injection Weil: fr. ft
OAquifer Recharge ❑Groundwater Remediation
19.SAI QF/G)AA1lEL FACIA(d appGcable
_ DAquifer Storage and Recovery ❑Salinity Barrier ;;Itort TO ntaTlsRUL EniPL2CiT.a�NT hIE'FHOD
DAquifer Test DStormwater Drainageft
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessa
OGeothermal(lleating/Cooling Retum) ❑Other(explain under#21 Remarks) 'rRollf TO DESCRIPTION color,hardness soii/rock type,gmin sae,etn
v IL IL S
4.Date Well(s)Completed: �Q' Well ID# b / fr f ,
Ss.Weil Location:
Phone # 0 y q/Z-73.f3 3U 3 Y So '
V h/� fr. fL
Facility/Owner Name Facility ID# ifhcable) ft. ft
( apP�
6-ply ft ft.
Ic
Physical Address,City.aid ft. fo S E P
21.RRMARKC
County Parcel Trim cation No.(FIN) Information ro
ces�illy Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34CO 27, J2., N Al", W
6.Is(are)the well(s): Wermanent or OTemporary Sfgnanae of Certified Well Contractor Date
By signnrg this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or ON/, 15ANCAC 02C.0100 or 15A NCAC 026.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and m plain the nature of the of this record has been provided to the well owner.
repair under#21 rrmarks section or on the bast ofthisform. 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 GWl1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: /
3�� z4.SUBMITTAL INSTRUCTIONS
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 ffdlfferent(example-3(a�00'and 2Q100� ) Y p p
24a. For A T Wells: Original form to Division of Water Resources (DWR),
Ifwaterlevel is above casing,use
f Static water level below top of casing: (D) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
N f
11.Borehole diameter: (in.) Bit Off: S� '7Sd 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
r rrr Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) U Method of test: r/r � �x,�• � N�t.t 2 f�S try npC
13b.Disinfection type: 70%HTH Amount 2 C. OZ DATE SITE VISITED: F'6ftG
1pk It 7W VISITED BY: A 1g
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 6-6-2018