GW1-2021-05354_Well Construction - GW1_20211013

A.
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Well Contractor Name
. �y51A OC� 132�21 ft. 3?8ft. sc�►,,. � ,!
IVC Will-Contractor Certification Number 3t1O.PrOCeS is.OUTER CASING for multi-cased trills dR'LDVER if a Geahle
YADKIN WELL COMPANY,INC. I�t�OrTT p���SgCY!On rRons TU nlan�talt TTffCru�ss TERIAI,
ft. ft in
Ln
Ccmipaay,Naaie ? 16.IlVNM CASING OR TUBING othermal closeA-loaml'
2.Well Construction Permit#: ) 3® 3 13 FROM To D1UKETER I 7MMO S I MATMAL
List all applicable well construction permits(Le.WC,County,State,Patiance,eta) 4-1 ft ! 71 R' &S in. , J 62 9 V
1 3.Well Use(checic weiI o-se): ft. ft. in.
Water Supply Well: 17.SCM,2i l
rv-.Gri MOTS-'Zr I TrTtCHIirsG I
❑Agriculttual ❑Municipal/Public ft. ft. in.
OGeothernial(Heating/Cooling Supply) gesidential Water Supply(single) Ft. ft. in
r' 01ndustrial/Conmiercial ❑Residential Water Supply(shared) 18.GROUT
J ❑Irrigation ❑Wells>100,000 GPD reord TO MA-1E T.L KMr nCEMENT POT HOD c al rOuxT
Non-Water Supply Well: it.
7 ❑Monitoring ❑Recovery fG '
23 a
Injection Well: sJKK
ft. ff. .
• ❑Aquifer Recharge ❑Groundwater Rtmediation f
19.uAPffI/GRAIrEL PACK(if ap licable
❑Aquifer Storage and Recovery ❑Salinity Barrier Fr_oni TO MATERIAL LI iPF etCiT.iS[V r hII TdoD =
r'f` ❑Aquifer Test pStormwater Drainage ft.❑Experimental Technology ❑Subsidence Control & ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa r 1rROM To D1.sC1rsTlox mlar.hardam deLfruclr -;ae,* ;❑Geothermal(Ileating/Cooling Return) ❑Other( Iain under#21 Remadts) ft
t 170.ft
4.Date Well(s)Completed: Tp
9b 1
5a.Well Location: Phone #
y
V f erY1�'j L� 11ei/
VV
Facility/Owner Name Facility ID#(if applicable)
L
Z 3� a �i 4 RC (33`'yS6�'uy _. ft: _.
i Physical Address.City.and Zip i'1 0awrOIL, C--2,)04Q,/
I 2L REA APM
V e- y w R
I County Parcel Identification No.C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
33, Y9 z S w 2..!!S.. W
6.Is(are)the well(s): Permanent or ❑Temporary Si of CLrk1kd Well Contractor s, Daft" '
Bysigningthisfarm,'!hereby certify that fha`well(s)was(were)constructed in aeeordonee.with
7.Is this a repair to an e:tisting well: ❑Yes or AS0 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and thof a copy
If this is a repair,fill out lonown well construction information and Mlatn the nature of the of this record has beenprovided to the well owner.
repair under#21 remarks section or on the back afthisform. 23:.5ite diagram or additional well details:
' 8.For Geoprobe/DPT or Closed-Loop Geothermal Wills having the smme You'may use the back of this page to provide additioual well conshuchon'mfo"'
construction,only I GW--1 isl�eeded. Indicate TOTAL NUMBER of wells C�d'See Over'in Remarks Box).You may also attach additional pages if necessary.
dnIledt: C r ^ 24.SUBMITTAL INSTRUCTIONS N •.j
9.Total well depth below land surface:
For multiple wells lLrt all depths ifr6�erent(ezamp/e-3Q200'and 2QI00� ) Submit this GW-1 within 30 days of well completion per.the following fl t
. :.
24a. For Wells- Original form.to Division of Water Resources R �?
I0.Static water level below top of casing: ��l7 A) All -� (DW
) �1
If wafer level it above rosin&,use"+" Information Processing Unit 1617 MC,Raleigh,NC 27699-1617
11.Borehole diameter: & (in,) Bit Off: �i r V,� 24b.For Infection Wells:Copy to DWR,Underground Injection Control
Programs 1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open Loop Geothermal Return Wells.'Copy to the
(ie.auger,rotary,cable,direct push,etc.) county envu-onmental health department of The county where installed TTT jjj
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wens pcoducin oval•166000 GPD:Copy to DWR,CCPCUA
Raleig
Permit Program;1611 MSC, h; C 4611 N 27699 �01
13a.veld(gpm) S Method of test: 9/t P' � }ALGA �h �i
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: ._ `-qZ •`
VISITED BY
Form GW-1 North Carolina Department of Envu�mental Quality-Drvisi6]i of Water Resources Revised 6 6 2018 sg,