GW1-2021-06789_Well Construction - GW1_20210809

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Well Contractor Name r%�•P.1 TO I rr�•iit3i i
3®3d tio�� �,,,,t Ss ft. �6 �. u f130
NC Well Contractor Certification Number P��C� �5�r� fLJrr *390
YADKIN WELL COMPANY,INC. Y O�C�( o`O FR OUTER COM A-SING formuDi �serddls pRT�LINER s a IicablRid T.
Company Name pJ
ft. in
16.)NNaFi CASING OR TUBING(' othermal closed-loo }
2.Well Construction Permit#: FROM To I DIAMETER I TwrmewESc MATsnreT• �1
List all applicable well construdlon permits(te C,County,State,Valiance,etc.) 2 ft. 37 in. Or O OO�p.Q//i re- I
// 1.
3.Well Use(check weil ruse): ft• ft. io.
Water Supply Well: 37.SCRs PI
FRON TO DU_PAETE.1 5LOTME TM004ESe H-T-LMr'_L
❑Agricultural ❑MunicipaUPublic ft.
❑Geothermal(Iieating/Cooling Supply) Atesidential Water Supply(single)
❑Tndustrial/Commeroial ❑Residential Water Supply(shared) I&CP.OUT
❑Irrigation ❑Wells>100,000 GPD MON TO IrfATEt�L ar.IPLACEn�wT r.�T9OD r A1:•IouNT
Non-Water Supply Well: 6) it. 3 ft
r•�
❑Monitormng ❑Recovery Injection Well: 3 .2 ft ft t
� S fP U Y%,
ft.❑Aquifer Recharge ❑Groun ft. (1dwater Remediation 44`
❑Aquifer Storage and Recovery ❑Salinity Barrier 14.SaSCLs/Gf'Ai'EL PACK(itapplicablel
FROM TO hlATERrAL ENT Cc'T.MiT hIL'er OD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Fleating/Cooling Retum) ' ❑Other(explain under#21 Remadm) FROM To D2SCRIPTION mlor,hardness,soithaelc sae,etc.
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a.Date wel,lsl(hmnleted:7-A_Z fL
5a.Wettx gcggromr� d. 'KPhon�e�# � ��1� 3`f' " v f Z
�� �`.`s fn. �`ll,��.a � �' 8,�, 4v,,sS�1�.•awni..P �
Factlity/Owner Name p Facility ID*ID#(if applicable) Z f ((3 v ft. v�
ft ft.
Physical Address,City,aaa 71p Old- Y®3 /lPrl Gn,Jtr,
IV 4j.'r,'�ot� 21.RLMAFM
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient)
22.Certification:
�E Oft f?6,r N 5-3 W r? q
6.b(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)HIp(were)Constructed in accordance with ^
7.Is this a repair to an eroisting well: ❑Yes or o ISANCAC 02C.0100 or 1SA NCAC 01C.0200 FeII Construction S/andardr and that a copy r , `
If this is a repair,fill out known well construction in/b matian d explain the nature of the of this record has beenprovided to the well owner. v J
repair under tell remarks section or on the back of this form.
23.Site diagram or additional well'!details:
8.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to,provide additional well construction info i
construction,only 1 OW-1 is need e Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary. r--
drilled:
�+ °�1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r U3 (ft) j
Formutilple wells list all depths ifdijjerent(exorple-3®200'ana!2@100) Submit this GW-1 within 30 days ofwell completion per the following:
1
10.Static water level below top of casing: 4D )(ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaterlevel is above cdsmg,use"+" / Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) Bit Off: 24b.For Iniection Wells:Copy to AWR,Underground Injection Control (TUC)
Prognun,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,direct push,etc.) county environmental health department of the'county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells-producing over;100 000 GPD•Copy to DWR,CCPCUA
Permit it Progra 161i-MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: GCG� m, I
i
13b.Disinfection type: 70%HTH Amount: Ll OZ DATE SITE VISITED:
VISITED BY. y/7
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources R. ;..a r;_A-,)nr s n n