GW1-2021-07146_Well Construction - GW1_20210915

Well Contractor Name IL ft.
a
a4sa a - 1`' •,��`'`` ft. aoa ft. � GPD: �'
NC Well Contractor Certification Number �`�� C!,?+ 5� 15.OUTER CASING for multi-cased wells OR LIIdL+R if a livable
YADKIN WELL COMPANY,INC. Oto�C gG�� FROM TO DIAACTUI TSIUaZss MRUL
J` Q.� �
Company Name \<<
1G.INNER CASING OR TUBING 'otherna!'�losed-loop)
)
2.Well Construction Permit#: O ��� 0M To DIPII�/TL+R TffiQav>ss IvtATaR7AT,
List all applicable well construction prm eits(i-e.WC,County,State,Variance etc.) ft V C
in.
3.Well Use(checll well rse):
Water Supply Well: M 3CFtEs�1
c—•�GF.i TO Di:_C9ZTit' SLOTSIZB THIClt7iEs0 I I:•]kT%ni.3. .
❑Agricultural ❑MunicipaYPublic ft. ft.
❑Geothermal(HeatineCooling Supply) Mesidential Water Supply(single) ft• ft in; \0
01ndustrial/Conimercial ❑Residential Water Supply(shared) I&GROUT
❑Irrigation ❑Wells>100,000 GPD Frrord To r.4ATERIAL EMPLACERENT 67
3ba "°i
Non-Water Supply Well: it 3 ft' Flc�e,Pl� ?ou�ra
❑Monitoring ❑Recovery 3 ft' 30 ft OutCk'Geasl tow mwy A2
Injection Well: ft. ft q u
❑ uifer Recharge ❑Groundwater emediaon
A4 R ti
g 19.fiAl`TD/GPAI'FL PraClf(if aDrvucable) ' '
❑Aquifer Storage and Recovery ❑Salinity Barrier r-e0r.1 TO I MATT RWi I EMPLACia M4-1 mri—HOD 1
❑Aquifer Test ❑Storurwater Drainage fL ft j y r
t '` ❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nenessa
FROM TO DPSCRIPTION color,hardness sailhoeic type,gmin ske,etz
❑Geothermal(11*eating/Cooling Return)i . OOther(explain under#21 Remarks) n ft. —ffl ft. yr
f AAOp A—
d: i1
4.Date Well(s)Complete 8 eo a( Well LD# S `]O ft Z2ft
5a:`(Well Location: Phone
J}��ltrtls �S •'7��i ft ft. e �� '1
Fac1 /Owner Name Facility ID#(if app�livable)
ty /� t ,! J 1
/) Nr.�C,- RAY 4 � f"lri,�GI'T ft
- ft_ ft.
Physical Address,City,and Zip
2I•REMARKS
G✓�i 16Ce S.
County Parcel Identification No.
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification
3l_17 g6ot N �� , r'I��' w
6.Is(are)the well(s): Permanent or ❑Temporary Signature f d Well Contractor Date
By signing this form,f hereby certify that the well(s)was(were)constructed n accordmuce wtt/t
7.Is this a repair to an existing well' ❑Yes or ONO 15ANCAC 02C.0100 or 15ANCACO2C 0200 Well Construction Standards and that o copy
If this is a repair,fill out(mown well construction information Aid explain the nature of the of this record has been provided to the ti#fl owner. _
repair under#21 remarkrsection or on the back of thisform.
23.Site diagram or additional welfde`tail
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
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
i
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '7 as (ft)
i; Submit this GW-1 within 30 days of well completion per the following.,
For multiple wells list all depths tf different(example-3@200 and 2@100)
' 24a. For All We11s: Original form to Division of Water Resources'
10.Static water level below top of casing: 1 dd (ft.) Information Processing Unit,1617
NEC,Raleigh,NC 27699-1617
If water level is above casing,use
1 Bit Off G 'dL—f 24b.For Injection Wells:Copy to�DWR,Underground Injection CoatioI(IiJG�
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,NC 27699-1636
t ; i �r
12.Well construction,method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,iirect 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
f Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test:
o DATE SITE VISITED: S k l in� �"J
13b.Disinfection type: 70/o HTH Amount OZ [Ct
,/ 1
4 VISITED BY: y i 1` `) >le
Form GW-1 North Carolina Department of Environmental Quality,-Division of Water Resources � Revised 6-6-2018
tVatrG '