GW1-2021-06795_Well Construction - GW1_20210809

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Well Contractor Name
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NC Well Contactor Certification Number 15.OUTER CAS far multi rased wells OR L17dER if a plicable
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YADKIN WELL COMPANY,INC. c
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Company Name C C�
��!�'� 16.INNER CASING OR TUBING othermal dosed-loop)
- I S FROM TO DLr METER .TMaC4ESS MARIALTE
2.Well Construction Permit#: ® W 'h '`�
List all applicable well construction permits(re.UIC,Cormty,Stater rion e,etc.) ('R 13 fi 6 t 0!t in- SD'g-a fe,
3.Well Use(check well use): ft in.
19.
Water Supply Well: -6
P'%QT.i TO Dint:? TnR SLOT Sr'% TuiC;04=SS i.7:T%iiAl.
❑Agricultural ❑Municipal/Public ft. ft. ;R.
OGeothemial(HeaunglCooling Supply) residential Water Supply(single)
01ndustrial/Conmierciai ❑Residential Water Supply(shared) i8.GROUT I(�
❑Irrigation ❑Wells>100,000 GPD F-10H TO PUTERIAL EMPLACEDIENT n•05-eaoD c AJr1OU1qr
Non-Water Supply Well: ® ft' 3 R ..' }4, u relvf 3 Y
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❑Monitoring ❑Recovery 3 ft. 31 fi• 9- ni 1 S
Injection Well: €t. ft
er❑A uif Recharge ❑Groundwater Remediation r
q � I9.SAPiIi/GRr117LL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROhI TO IYlATrRIAt, ir.IP1.ACEriENYIrI?;THOD
OAquifer Test OStormwater Drainage fi 0
❑Experimental Technology ❑Subsidence Control ft i
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Ileating/Coolmg'Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardneess,soil/racko type�grainsae etc V 7
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4.Date Well(s)Completed: 4c 17'.J- Well ID#4A0-T6 fy R' "1
Phone # 73L—LZ41 1rjg� IDA, (gd � $ Grc "+f'
Sa.Well Location: .. '
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Facility/Owner Naame/ j 1j /F�aciiiity ID#(if applicable) ft. R'
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Physical Address,City,as 4d Zi
IAI C S 21,REMARKS 11
County Parcel Identification No.(PIN) ARM `fl V- SfiT ta�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welllffield,oone�lat/long is sufficient) 22.Certification:
�LFa�—ter t�Z O N 191 O �D S� W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or , vo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information dnd erp/ain the nature of the of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
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 ofwells (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 �- (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all'depths if different(example-3@200'and 2©100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" (l
1 Bit off:��6 24b.For Injection Wells:Copy to DWI,Underground Injection Control (1UC)
11.Borehole diameter: (in) Program,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
(ie.auger,rotary,cable,erect push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducin2lover 100+,000 GPD:Copy to DWR,CCPCUA
qq r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J0 Method oftest: a�/� n
e DATE SITE VISITED: 7 �': l C/
13b.Disinfection type: 70%HTH Amount: `;. OZ . �4 1 �`
4MA - VISITED BY: i2A
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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