GW1-2021-06791_Well Construction - GW1_20210809

rRor.l TO ��S�T'TiON
Wdl Contractor Name �, at. -t. Per M t
f�+ GLS Maybes i / ow► r n
��S ' t1p1►` ft ft
NC Well Contractor Certification Number C t ��, 1.• i�j� 15.OUTER CA-MG for multi-cased wells OR LINER �a ticable
YADKIN WELL COMPANY,INC. \C� ��,r FROM DIARQtTER THIGTQIEss YL+RIAL
G.0
Company Name 16.EgNER CASING OR TUBING(geothermal closed-loo
i3t�. ®�+ FROM TO DIAMETER TMCED S5 MAMMAL �o
2.Well Construction Permit#: _,
List all applicable well construction permits(Le.VIC,Coon tale Valiance,eta)
�
3.Well Use(checlt well cs ft. ft in.
e):
17.
Water Supply Well: ,; I
L�1
reOT.i TO DU.r:lETa?.J SLOT SIZE T131C;4'tE'S6 R9-TiE1l:1
❑Agricultural ❑Municipal/Public ft. ft. in. .►�
❑Geothernial(Heating cooling Supply) Aesidential Water Supply(single)
.: t7industria]/Commereial ❑Residential Water Supply(shared) Ig Cr,UU'I
't ❑Wells>100,000 GPD Mont TO KA TEt�-L L�Mnacs r>FraT rlETgeD c al:tourvT
'( ❑Irrigatioll
N670- er Supply Well: it, ft
OMonitoring ❑Recovery ft ft
Injection Well: ft. ft
®Aquifer Recharge ❑Groundwater Remedistion
19.SASM•/GRAATIL PACK(if ap,licable
n ,qutfer Storage and Recovery{ ❑Salinity Barrier FEO114 TO hi TEEIAL ENTUCECa-M-1 NWISOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Expenmerital Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) []'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(5eating/Cooling Return) ❑Other(explain under#21 Remaild) lraont . To D1sseR�rtON eomn eardnrsc,sunlruclt e, °size etc
®oft nv
4.Date Will(s)Completed: 1S t7` Well ID# � ft
g:. '5a.Well Location:
fti ft
e G �r G G�/e,ey ft ft
Faca7ity/Owacr Name : Facility ID#(if applicable)'
ft ft
.Z,�.Z �e ot.>±!?�f/e�i.-G•h ��� �, "_ ft ft.
Physical Address,L'itN and Zip
ft ft
21.REMARKS
Co f �- PorcelIdmtificationNo.(FIN) Ogg
t
A ' 5b.Latitude and longitude in degrees/minutes/seconds or decimal;degrees:
(if well field,one nsuffiit) ;. 22.Certification: `
36' 6h, 3? N 6.Is(are)the well or , ❑Temporary
Si of C` ' e Well Contactor Date
a By signing thisform,l hereby terry that the well(s)was 6vere)constructed in accordance with.
7.Is this a repair-to an existing wen: � oT. `*No•'' 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Mel/Construction Standards and that d copy '
If this is a repair,`fdl out brown well constructiimation arrd ezplaln the natrir"i of the of Phis record has been provided to the well owner.
repair under -
23.Site diagram or additional well details:
c, 8.For GeoprobefDPT or Closed-Loop Geothermal Wells having the same
You may use the back of this page to provide additional well construction jilt
«;construction,only 1 OW-1 is needed.,Indicate TOTAL NUMBBR ofwells (add'See Over'in Remark Box).You may also attach additional pages if necessary
n drilled: [ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d� ft Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiferent(ezample-3Q200'and 2@100�
10.Static water level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resourtici l'DWR)
Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
lfwater level is above carting,use"+" `
11.Borehole diameter: (�� Bit Off:_ 24b.For Infection Wells.Copy to DWR,Underground Injection Control(IU`Q,. >
Program,1636 MSC,Raleigh,NC 27699-I636 T
12.Well construction method: AIR ROTARY � °j ' y •?
24c.For Water Supply and Open-Loop Geothermal Return WeIls Copy to the; '
(ire.auger,rotary,cable,direct push,etc.) 2
county ertviroxxmentalhcalth dcpertIItent of the county where installed'-
x
FOR WATER SUPPLY WELLS ONLY: 24d.For Water V -eus producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit program,1611 MSC,Raleigh,NC 27699-1611
13a.Y►eld(gpm) Method of test / /^
---�-I�.
13b.Disinfection type: 70%HTH OZ DATE SITE VISITED:
Amount: 3 i -
®0
r, S VISITED BY:
FarmGW-1 `' North.Carolina Department of Environmental Quality-Division bf Water Resources Revisedtib217I11 i-