GW1-2021-05570_Well Construction - GW1_20211013

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Well Contractor Name Fr:OGI 10 - u�SCr-Ti^II
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NC Well Contractor Certification NumbertCGg'$O(\ Sc OUTER CASING farmullirased ells ORLINER ifs livable
YADKIN WELL COMPANY,INC. �p�p cj�,Ol rROM To DlAnmrreR 55
Company Name "s se l..33(W-k v 7 V1. 3-;1 16. CASING OR TUBING thermal dozed-loon)
2.Well Construction Permit OU-s F Q / /o Y�S' FROM To DLAWiTER �TMCEMSSn MAT x
List all applicable well construction perzOls(i e.UDC,County,Slate Valiance,etc) ft 9 y ft• C� �At nn
3.Well Use(check Fell r.se): ft• ft in.
Water SupplylKrefl: 17.SCF,Tzi a I �s �- �
Rrtord T O DIA_l:'IETC� LOT SrZZ TMC.4dES0 PIAT-M ALL .�
V�ricultural OMunicipal/Public ft. ft
OGeothemial(Heating/Cooling Supply) Wesidential Water Supply(single)
ft
❑Industrial/Commeroial ❑Residential Water Supply(shared)
l9.GROUT
❑Irrigation OWeds>100,000 GPD MON TO nfATM&L EM PLACEWNT METHOD t-AJ-1OUNT ��
Non-Water Supply Well: U it, 3 ft. A*A,h `jrc�: 3 (�•
OMonitoring ❑Recovery 3 ft. Z 3 ft ,fit r ® �L ?�
Injection Well:
ft. ft ! ��
❑Aquifer Recharge OGroundwaterRemediation 19.SAS[D/G1oA1rEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRon4 TO rrwTExIAL HELHOD
❑Aquifer Test ❑Stormwater Drainage ft ft (�
❑Experimental Technology ❑Subsidence Control ft 5
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLDVG LOG(attach additional sheets if necessa
❑Geothermal%eating/Cooling Return) ❑Other(explain under#21 Remarks) 1
PROM TO DESCRIPTION color,bardnen,toiltrock type,grain dve ete
77
4.Date Well(s)Completed: Well ID# AAO COI 6.,ftft ft
/� a
Sa.Well Location: Phone # 2J1.� 23®"T 7� yfv • •/ ft Q� tom/' `
ft. ft.
S(Ah&A�e 9-e d�,�a
Facility/Owner Name Facility ID#((f applicable) ft• ft
2 8 qv ft. ft
Physical Address,C iM aid Zip ft ft
t Ci k 1 r 21.RFnRxs
County Pareel Identification No.CM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,me Wong is sufficient) 22.Certification:
3Go o 0 70 N k90' 4 /0a w _
6.Is(are)the well(s): idermanent or []TemporarySigoahae of Certified We➢Contracror Date
A, Byslgni g thivform,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an cxLOng well: OYes or &No 15A NCAC 02C.0100 or ISA NCAC OlC.0100 Well Construction Standards and that a copy
Ijthis is a repair,jrll out brown well construction information and explain the nature of the of this record has been provided 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 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 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: (ft)
For multiple wells list all depths zf differelnt(emmple-3@200'and 2(a)1001 Submit this GW-1 within 30 days of well completion per the following: .�
10.Static water level below top of casing: t/ o (ft) 24a• For All Wells: Original Bonn to Division of Water Resources (DWR), N
Information Processing Unit;1617 MSC,Raleigh NC 27699-1617
Ijwurter level is above casurg,use"//+" � N
11.Borehole diameter: b Gn•) Bit Off: S�9l� 24b.For Injection Wells:Copy to IJWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12,Well construction method: 24c.For Water Supply and Operi Loop Geothermal Return s Wells:Copy to the
(it.anger, cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) 0 0 Method of test: r • 2/r Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH OZ DATE SITE VISITED: —1 2. -Z/ ��� ,1
13b.Disinfection type: Amount: .Z� .�� �O
/'A t l f VISITED BY: ::r W i l7 2P
I—GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018