GW1-2021-05330_Well Construction - GW1_20211013

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Gonhaetor sine � isTOt:lt�\i3Of��l� �C-�•LLljjt
NC Well Contractor Certification r � •. �_ .. .; .. ` �'�Y �-�I;� -_�„ •� '���
Number M / ' p
BS�*o 15.OUTER CASING for multi cased ivdis d 1 iiii licable
Llo 100 PROn2 AS DIAa ZUR TSICi=SS T6RIAL
YADKIN WELL COMPANY,INC. r 3 QC�'On ft. J ft. is
TO
Company Name P 16.]INNER CASING OR TILTOING othermal closed-loop) y
F's 2.Well Construction Permit#: (p .A( F1tOM I TO DIP TIIt MMLUNPSS
List all applicable well construdlon permits(l.e.UIC,c5urity,State,YarlancA etc) I
ft. ft. ' in.
3.Well Use(elect[IRIell LEE): i
37.SC-IX-7 I
Water Supply Well: e-r_Orri TO Dill METE. SLOT SIZE TEFIC:134ESS [A-i LPi=i
❑Agricultural ❑Municipal/'Public ft, ft In•
❑Geothermal(13eating/Cooling Supply) �Lesidential Water Supply(single) ft g,
❑lndustrial/CommerciaV (❑Residential Water Supply(shared) lq c-R-OUA
❑Irri ation.. ❑Wells>100,000 GPD MON I TO AIATERL3.L EMPLACE14ENTr.JET HOD r FJ:IOUNT
Non-Water Supply Well: O !�' t 1111� i
❑Monitoring ❑Recovery �� R Oe l n, l o►r/ 0M
Injection WeU: ft ft
DAquifer Recharge ❑Groundwater Remediation
19.SAPID/GRAVE',PACK(if-applicable)
❑Aquifer Storage and Recovery DSalinity Barrier FROM TO ntATLRIAL El iPLACerrE -1 TeXi-rIOD
r
❑Aquifer Test OStornrwate Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 2o.DRMLING LOG attach additional sheets if nemsa )
PROM TO DESCRIPTION color,hardness sontrack in sae,ett.
❑Gerthermal(lleating/Cooling Return) ❑Other(explain under 421 Remarks) 6 ft. i
4.Date Well(s)Completed: WeU 1D# ®l R fi prat✓
fL
5a.Well Location: Phone # $'03-32 5-5036
Sc�af �a` anti ,-ham SO, ra r&A t
Facility ID#'tf apP licable !v lGk I /-
O FacilitylOwnerName i` ) t�d t
ft ft.
ft R
Physicaldres
/Ads,C,,itty.and Zip L>✓n Ir1 (1y j Sf r
Q�!r kne, a�fWX 21.RI:MARKS
i
7- county Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lknong is sufficient) 22.Certification:
4 6.Is(are)the well(s): ermanent or ❑Temporary Sigoatmn of Certified Well Contractor Date
Bysignmgthis form,l hereby certify that the wells)was,(were)cqutructed in accordance with d
4. 7.Is this a repair to an existing well: ❑Yes or *90 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard[and that a ropy
of the record eenpd has b rovided to the well owner.
Ifthis is a repair,fill out known well construction information d explaln the nature of the
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Qosed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is negded Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box):You may also attach additional pages if necessary.
drilled: j 74.SUBMITTAL INSTRUCTIONS
L1,.. 9.Total well depth below land surface: 42 (ft) Submit this GW-1 within 30 days of well completion per the following:
Par multiple wells Its[all depths if different(example-3@200'and 2(df100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ��ft) Formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use \l
Bit Off: ,a 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
11.Borehole diameter:_�(in•) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constriction method: AIR ROTARY 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 tare county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Ralei%VG 27699-1611
13a.Yield(gpm) Method of test: R!l� ®
o HTH
13b.Disinfection type: 70/o Amount: OZ DATE SITE VISITED:
VISITED BY: