GW1-2021-06071_Well Construction - GW1_20210809

Well Contractor Name ft. ft.
NC Well Contractor Certification Number —15.OUTER CASPIG(for ulti-cased Nvells)
LFR To T PETIJIMRUI J'i=T11,11L
YADKIN WELL COMPANY INC. ft. in.
16;
Company Name 16.EVNZE R CASING OR T G(geothermal dosed-loop)
_ _ t��
2.Well Construction Permit N: -3 FROM I TO DIAME TER RLAL
List all applicable well construction Permits Ae.UIC,County,State, Mariance,etc.) ft. S11 ft. in- 0
3.Well Use(chech well use):
rRop"I TO DI-1,PIETER SLOT SIZE
ElGeothermal(Beating/Cooling Supply) tZesidential Water Supply(single) ft. in;
Non-Water Supply Well:
oMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
19.SAND/GRAVEL PACK(if applicz1ble)
DAquifer Test ostormwater Drainage
DExperimental Technology oSubsidence Control
DGeothermal(Closed Loop) OTracer 20.1)RILL]ISIGLOG(attac additional sheets ifnecessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type�grain siz&rMl
oGeothermal(14cating/Cooling Return) 00ther(explain under#21 Remarks) <ft.
4.Date Well(s)Completed: Well ID# 1+14 ft, ft.
Phone #
5a.Well Location:
I Faicility/Owner Name Facility M#(if applicable) ft.
Physical Address,City,and Zip nN
Parcel Identification No.(PIN)
5b.Latitude and longitude in M"ies/minutes/seconds or decimal degrees:
(if well field,one lattlong it suffidet), 22.Certification:
6.Is(are)the well(s): OPermanent or OTemporary Sigzla+of Ceilified Well Contractor Date
7.Is this a repair to an existing well: Kies or 8No 0&-.V C3,p 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and.explain the nature ofthe ofihis recordhas beenprovided to the well owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havmig the same You may use the back of this page to provide additional well construction info
(add'See Over'in RemaAs Box).You may also attach additional pages ifnecessary.
construction,only I GW-1 is ded. Indicate TOTAL NUNMERofwells
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths itdifferent(example-3@200'and 2@1 OOD I
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top pf casing: 30 (ft*) Infbrri�a—tion Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter: 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.Flor 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: 24dMor Water Wells producin�over 100,000 GPD:Copy to DWR,CCPCUA
13b.Disinfection type: 70%HTH Amount: 0z DATE SITE VISITED: 4/—�z
VISITED BY:
Form GW-1 North daimlina Depax6ent of Environmental Quality��Division of Water Resources Revised 6:6-2018
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