GW1-2021-05327_Well Construction - GW1_20211013

1J,
J
AA
FROM TO I DL34CRHTi0T1
Well Coutraclor Name t Nq T--D
105ft. 101 1 P
wA --e
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASPIG(for multi-cased wells)OR LINER if applicable)
YADKIN WELL COMPANY,INC. 00R t FROM TO DIAMETER THICKNESS I MATERIAL I(3Z ft. I I Ll in. I
Company Name 5-0 IM
vro' -
sec; 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 35"* FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft- 7, 00 "a- - 15',0 9(ack
3.Well Use(check well use): ft. ft, in.
Water Supply m1ell: 17.SCRZEN
FROid TO Dl,?,-!rTE;I. SLOTS!ZE TMCBTIESS H A T E PU'La-1
DAgricultural DIMunicipal/Public ft. I ft. in.
EiGeothernial(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. in.
01ndustriaUCommercial DResidential Water Supply(shared) 16.GROUT
DIrrigation DWells>100,000 GPD frIn-IIII TO MATERIAL ENIPLA CEP.-TENT Nf,:TH0D,!A0.10UPIT
Non-Water Supply Well: 0 "1 C1
omonitoring EIRecovery 08414 T-
Injection Well: F4
DAquifer Recharge DGroundwater Remediation 19. PANCIi(if applicable)
DAquifer Storage and Recovery DSalinity Barrier, FROM TO MATERIAL; Ep.ip AC:1-1,1ENTHWHOD LZ
ElAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft• ft.
oGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM to DESCRIPTION(color,hardness,saillrock type,grain size,etc.)
DGeothermal(Ileating/Cooling Return) 00theF(explain under#21 Remarks) 't,
ft
ft-
4.Date Well(s)Completed: -),I Well ID4r+0- 5').?
�Zft JA4 6/9 10, /
5a.Well Location: Phone # 1,0 7 9 1(0 iltv-dz
ft.
SO -rvi t
Fa lilt Facility ID#((if applicable) ft- ft. U ar
3 *dJ 4 ON U ft- ft.
Physical Iddress,City,and Zip ft. ft.
21.RE,NIARKS
Co Parcel Identification No.(PR)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one)at/long is sufficient) 22.Certification:
TT-7- N �l 33, 3 a- 6 1 W
6.Is(are)the well(s): EVermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes Or 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction informat in the nature ofthe of this record has been provided to the well owner.
io A and explain
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
J <
-1,% 8.For Geoprobc/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 I GW- 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: 3n, (ft-) th
For multiple wells list all depths if different(example-3@200'and 2@1005 Submit this GW-1 within 30 days of well completion per the following: 10
24a. For All Wells: Original form to Division of Water Resources (DWR),10.Static water level below top of casing: (ft-) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter: '�� (in.) Bit Off: 9�?O- 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 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
(i.e.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
13a.Yield(gpm) 3 Method of test: Permit Program,1611 MSC,Raleigh,S I NC 27699-1611 ot 4�04'
Oz DATE SITE VISITED: .57 et
13b.Disinfection type: 70%HTH Amount:
VISITED BY: 1/13
Form GW-1 North Carolina Department of Environinental Quality-Division of Water Resources Revised 6-6-2018
P,I C E
0.11C 01.-B' -&' TA.