GW1-2021-07095_Well Construction - GW1_20210915

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well COIItraCtar iQemE_ Molt TO Ji'!1!'I t
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NC Well Conttactor Certification Number �� 2 ova
15.OUTER CASING for multi-cas veils ORLINER ifapplicable)
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YADKIN WELL COMPANY,INC. FROM To DIAIiSTCR THItS si AIATERLAL
Company Name p
S u✓py 33(e I' - O ITZ'Y, 16.IPIIVFZt CASING OR TUBWG atbermal closed-loop) fr
2.Well Construction Permit#: P(Z W 4-2-a2.1 0203 2. FROM To I DIA.IIETER I TtilORMSS MATERIAL L/
List all applicable well construction p6mlts r e WC,County,State YaHance,dc) R- q 3 ft 16 ,14 m. ov .11
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3.Well Use(cheat well use): ft. ft in.
Witter Supply Well: 17.SCr-r2l I t
pp y F11.01A TO nL'.NEM-A SLOT SIZE TSlC14tESG r:9-iTi Pi1L
❑Agricultural • OMunicipal/Public ft. in.
❑Geothermal(Heating/Cooliag Supply) OVsidential Water Supply(single) ft I n,
01ndus(riallCommercial ❑Residential Water Supply(shared) 11; GROUT
OIrrigation ❑Wells>100,000GPD MOM TO HATE[u., EhIILAC-0ZNTPIETSOnfA&IOUNT
Non-Water Supply Well., O it. ft.
❑Monitoring ORecovery 3. Iti) ft ` p� 3}/
Infection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SASIi1/GRAI,L PACK(if applicable)
❑Aquifer Storage and Recovery OSalinily Barrier FROM TO MATERIAL LWLACiT.f-Ni ME'!'rIOD
14- -123
❑Aquifer Test ❑Stormwater Drainage M ft.
OExperimental Technology ❑Subsidence Control M
❑Geothermal(Closed Loop) ❑Tracer 2 .DRlLLI1VG LOG attach additional sheets if necessary)
❑Geothermal Meating/Cooling Return) ❑Other(explain under#21 Remarks) FROH TO D28CRIPTION color,bardnes:soil/rack •a sae,�
4.Date Well(s)Completed: .�^oZ. WellID#gf�ildln�� s l /�y ( Z R' 1�!
5a.Well Location: Phone #.�(/ `-fQ r-6�T (, G �7't::l
ft*
6 -
Fam'h &Owner Name Facility ID#(if appIi-ble) �2 ft. 2 10 ft. $®r-} t j t
J 9 , ay 1' t/ 1�.1�!� �s,�$o *1 oh 1 & 3® ft' 1 G r
Physical Addres%City,add Zip ft ft
21.RRMAPM
County Parcel Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Crfwell field,me Wong issufficient) 22.Certification: K3�:0�}�1^ov(sp(1
3C° �3 - Sit N �c�' _ � «;. Y
W ,tl p UR `-/�• �/
6.Is(are)the well(s): Vermaaent or OTemporary rgnafire of(:certified Well Contractor Date
Bysigning thisform,1hereby certify that the well(k)was(were)constructed in accordance with
7.Is this a repair to an eusting well: ❑Yes or a, 1SANC4C 01C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information and explain the nature afthe of this record has been provided to the well owner.
repair under#21 remor/a section or on the back of this farm.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. d
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ©y (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Arm all depths if different(example-3@200'and 2@100�
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be of casing: 7,� ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levelbelow top,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is able
11.Borehole diameter (in.) Program,
Off: .V 24b.For Injection Wells:Copy ItD 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 W. ; ropy
(i.e.auger,rotary,cable,direct push,etc.) county environmental health depaitnient of�the county where'
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 100,000 GPD: y to DV ?,CCPCUA
t t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 160 Method of test: P&L,�
Sr A// I ; dw
13b.Disinfection type: 70%HTH Amount:
�' t r OZ DATE SITE VISITED: ?
M 16 * T-N VISITED BY: Divi f C4t��S.�&,e"
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ` Revised 6-6-2018
D e r r c in -%1 .•.71 in I f9 d2- NIL