GW1-2021-06301_Well Construction - GW1_20210915

Well Contractor Na ITE.C.i.l TO DZSC[=,Ti011
7 ft.
- 1
NC Well Contractor Certification Number ;\ 15.OUTER CASING for multi-cos ells OR LIIVER if a lieable r�
YADKIN WELL COMPANY,INC. �6 0 � FROM TO DMI TER TIIICItNEss MATERIAL
ft. ft. in.
Company Name 16.JNNsM CASING OR TUBING(geathermal closed-loop)s
2.Well Construction Permit#: FROM TO DIAMLrTER I THIG[OESS MATRRTAL
List all applicable well construction permits(te.UIC,County,State,Variance,eta) ft 39 ft- 0-11 In' J��2 71 P 1/C-
3.Well Use(checl(Weil tse): ft. ft. in.
17.SCRE2N
Wales Supply Well:
i.POrd TO DL`-NETER ELOT SIZE T5109d1ISS P..1-T£P.i-'1.
❑Agricultural ❑Municipal/Public ft. ft in. (�
❑Geothermal(Heating/Cooliug Supply) residential Water Supply(single) it ft, in.
❑Industrial/Commeroial ❑Residential Water Supply(shared) 13,GROUT - I
❑Itrigation ❑Wells>100,000 GPD moot To P.a,%TrtuA/v- EMPLACEMLNT METHOD&A1.IOUNT
Non-Water Supply Well: b tl' ft Yir-fie` O tJ r
❑Monitoring ❑Recovery R �� ft ;S1t+f /"l
Injection Well: ft. ft
❑Aquifer Recharge OGroundwater Remedistion
19.SAT1S}/GRAirI,PACE(if applicable)
❑Aquifer Storage and Recovery oSalinity Barrier ROM TO MATERIAL I EMtBLAGc.rsn�-7r ML'i EOD
❑Aquifer Test ❑Stormwater Drainage ft, f
❑Experimental Technology OSubsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessa ,)
FROM I TO DESCRIPTION color,hardness soil/rock type in sae,eta
❑Geothermal(Ileating/Cooling Rrhun) ❑Other(explain under B21 Remarks) Q ft
4.Date Well(s)Completed: T-J WellID# Z1,2461` 7 ;Lft' Z1101ft fr$ �f /�• rM.
Sa.Well Location: Phone
ft ft
FF ty�Name Facility ID#(if cable) ft. f
/W C4t!It f I ft ft
R 03 7 0?,^very � 0!U.
Physical Address,City,and Zip ft ft
60 4� -V /,P., 21.RRMARKC
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,me lat/long is sufficient) 22.Certification:
6.Is(are)the well(s):Je ermanent or ❑Temporary Sif&42fc of Cedified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well; ❑Yes or 0 15ANt:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information an explain the nature of the of this record has been provided to the welt awner.
repair under 921 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprabe/DPT or Closed-Loop Geothermal wells having the samel
construction,only 1 G I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .�6.2 (ft) Submit this GW-1 within 30 days of well completion per the following:
Fos multiple wells list all depths tfdifferent(example-3@200'and 2(a)100D
10.Static water level below top of casing: �r ( ) 24a. For All Wells: Original firm to Division of Water Resources (DWR),
I10.stater tic
u above el casing use op Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
Bit Off: �' 3� 24b.For Injection Wells:Copy to DWI Underground Injection Control (IUC)
11.Borehole diameter: (in.)
) Program,1636 MSC,Raleigh,NC 27,699-1636
AIR ROTARY I
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: Cop
y to D WR,CCPCUA
Q Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) O Method of test: q f H InvAS90
13b.Disinfection type: Amount:70%HTH �• OZ DATE SITE VISITED: -�
�•oZ�•��
VISITED BY: �10
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019