GW1-2021-07084_Well Construction - GW1_20210915

I
Well Contractor ame - rr_(t
ft. 93 1.1•. r- /C.-,o T
NC well Contractor Certification amber t ZA IL (7,.)- ft
15.OUTER CASING for multi-ca tvel OR LIIVER ff a licable �
YADKIN WELL COMPANY,INC. FROn2 TO DIATOrTER i THICIINEss TE
It. I ft i in.
Company Name 16.1NNER CASING ORTUFIWG uthermalclosed-loa
2.Well Construction Permit#: AA FROM TO DL430TER 11 MU MATERIAL � 1
List all applicable well construc0on permits Le.WC,Comfy,State,Madame,eta) 4' ft-
-1 7 ft, vc
3.Weil Use(chectc well uxe): ft• ft. in. -�
li.5Ct.E2P1
Water Supply Well:
F!?GF.i 70 0L`_TirTR SLOT 51iE TtleC14iE50 t:l::iiPi:.i.
)ugricultuual ❑Mumicipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft,
❑Industrial/Commeroial ❑Residential Water Supply(shared) Ib,Gr,UU T
❑Irri ation ❑Wells>100,000 GPD MON I TO MAM AL >IM?'LACEhL NT 1`.0-1901)A A1r10UNT
Non-Water Supply Well: 0 t' . ft. 4y4-e , Da us ed
❑Monitoring ❑Recovery ft: ' ft. ij+
Injection Well:
ft. ft
❑Aquifer Recharge IZIGroundwatrr Remediation
19.5Al1ED/GRAi1;L PACE(a+•applicable)
❑Aquifer Storage and Recovery OSalinity Banier re011f TO MAMMAL EDUTA-iTMiT HLM-i 0n
❑Aquifer Test 08tormwalrs Drainage ft. ft•
❑Experimental Technology ❑Subsidence Contr01 ft. ft- '
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(1-Teating/Cooling Return) ❑Other(ekplain under 421 Remarks) 1r11onq TO DrsCRrMON color,hardness,sawrark typN -n sh,etc
4.Date Well(s)Completed: -70`a{ Well w# _rC 7 ;.oft. o i Al-""
5a.WellLocation: Ph.orle #_e���"�97 -T/9 1�5� r7®o � M V %t
Fa�ci-liitty/Owner Name \ 'I Facility M#(if appJi-ble) ft. ft
G�I�RI/ rk
fL ft.
Physical Address,City.and Zip & ft
f4d 2I.RLtMARIGS e
+a7 County <h Pared Identification No.(FIN) Q SFrt4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 22.Certification:
N W
i� 6.Is(are)the well(s): 14rmanent or 01'emporary Si of C4ffied 17611 Cimtractor Date
Bysignnigthisform,l hereby certify that the well(k)was(were)constructed to accordance with
7.Is this a repair to an existing well' OYes or 940 15ANCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out lanown wen construction information and explain the nature of the of this record has been provided to the well owner
repair under 921 remarks section or on the bark of this form.
23.5ite 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 OW is needed. Indicate TOTAL NUMBER of wells (add'See Ovice in Remarks Box).You may also attach additional pages if necessary-
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdi�ensu(example-3Q2 (fG) Submit this GW-1 within 30 days of well completion per the following: (/J
0 'and 2@100)
'30. 24a. For All Wells: Original firm to Division of Water Resources (DWR), i
10.Static water level below top of casing: (ft.) Information Processing Unit,1617i�MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off.. l0•03 d 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in)
Programs 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 push,ern.) 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
13a.Yield(gpm) Method of test: �tl✓TGrrvri--
70/a // ®® DATE SITE VISITED:-C-2.3'2,1
ke a V v1 ^\
13b.Disinfection type: ° HTH Amount: (fie® 0Z 1 •l1/- �' P
VISITED BY: f t doe /
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resournei Revised 6-6-2018