GW1-2021-06309_Well Construction - GW1_20210915

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WellCouhactorNat +'ROM O �F i_`iaC•il
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NC Well Contractor Certification Number `��e $5\r9 / c f L 3'>R 5 r i ® _ L
p\p0P' 15.OUTER CASING for mldti-Ca i wells OR LINER(if a plicahle
YADKIN WELL COMPANY,INC. 3`pt\ SQ FROIA TO nIAMETER T>DCrwnss TL+RUL
it. I ft I in.
Company Name
16.INNER CASING OR TUBING( thermal dosed-loon)
2.Well Construction Permit#: FROM TO DIAN ETER TEUCEMSs I MATEML
List all applicable well construdion permits(i.e.VIC,County,State,Yariance,etc) , 'L 12- ft• -1D
3.Well Use(check weal L•.se): ft. ft
Water Supply Well: 17.SCP,T2 i e Ori TG DLAMETE� y LOT SIZE I TMC_-NESO I PIATR L
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) v6esidential Water Supply(single) it. ft.
01ndus(rial/Conimercial ❑Residential Water Supply(shared) i; Cr,UU'I
❑Irrigation ❑Wells>100,000 GPD Front I To rtATEMAL EMPLACErrNT AIETSOD C.P13oUNT
Non-Water Supply Well: O N. # %
❑Monitoring ❑Recovery ft ft
Injection Well;
❑Aquifer Recharge ❑Groundwatrs Remediation ft ft
❑Aquifer Storage and Recovery ❑Salinity Bon 19.uAPID/GPAl EL PACK-(if ai,�ticable)ier FRold To MATERIAL I 00LA(iR,-L—LN-LA-M-LOOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(A'eating/Cooling Return ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain the,eta
4.Date Well(s)Completed. FfA Well 1D#AAA_ `'CZ C1 fL fLc5o4 op
e / Ct
5a.Well Location: Phone #�A q�Q���� � � Y�r . )
.�Qu' wGponCCV'
Q e .1 �.
Facility/Ovmer Nam Facility ID#(if applicable) ft. fL
G 7 5*3 FP I e 4A J Ck (2,"- Cr.-AWAvi"l( fL s.
Physical Address,City,and Zip ft fL
c___(• TCG�'d i 2L REMARKS r L
County Parcel Identification Nn.(FIN) —�L D J 7 (OW►� �D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,mela/iongis sufficient) 22.Certification: ,
6.Is(are)the well(s): Oermanent or ❑Temporary Si of C Well Contractor Date
BY ing thisform,I hereby cer fy thal the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing Well: ❑Yes or nNo ISANCAC 02C.0100 or 15ANCAC 01C.0200 Well Construction Standards and that a copy �+
If this is a repair,fdl out 70own well construction information and explain the nature of the of this record has been provided to the Well owner. t
repair under A21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
6.For Geoprobe/DPT or Closed-Loop Geothermal wells having the same (11
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. .-
drilled: 24.SUBMPITAL INSTRUCTIONS
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9.Total well depth below land surface: (ft) Submit this GW-1 within 30 da s of well completion per the following:
Formultiple we/lslirt all depths tfdifferent(example-3� @100J y p p
10.Static water level below top of casing: �D 24a. For All Wells: Original form to Division of Warner Resources (DWR),
(ft)
Ifwater level is above casing,use"+" ® Information Processing Unit,1617 MSC,Raleigh,NC 27699 1617
11.Borehole diameter: (in.) Bit Off: / 24b.For Injection 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
(Le.auger,rotary,cable,direct pusb,etc.) county environmental health depar�lent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) J Method of test: / Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY: O Or . J 16
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Form GW-1 North Carolina Department ofEnvironmental Quality-Division ofWater Resources d 6-6-2018 /