GW1-2021-05333_Well Construction - GW1_20211013

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Well Contractor Name 2021 - - 1 Lv,.l ft. To
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c9%4S'3 A ft I ft. �
NC Well Contractor Certification Number egSlllf�lllvt
Ir+3t1011 pfOc 1O is.OUTER CASING for multi-cased wells O!!_LIT
ER La liable
YADKIN WELL COMPANY,INC. �Pi O p�N�S ` 1 D FROMTo D>aA4L+TJ R TBICTOiLsS TSRUL
ft. ft. in
Company Name 16.IDWEIt CASING OR TUBING(zeathermal dosed-loon)
2.Well Construction Permit#: 6/ FROM TO DIAMTLR I THEGMESS MAT✓+R1nL
List all applicable well construction permits rLe (AC County,Slate,Vadancy elc) C R D• G ' 10 S p 1 P V L
3.Well Use(check well use): ft. ft. in.
Water Su 1 Wel!: 17.5CP_rZN
pp Y MOM TO DG_tdETZd SL AT SrZG TarC,7iu ss
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothemial(Heating/Cooliug Supply) ❑Residential Water Supply(single) it. ft in
❑Tndustria,(Commercial �2esidential Water Supply(shared) q GROUT
[]Irrigation ❑Wells>100,000 GPD ITorj I TO HA TERIAL EMLACEI�--NT VEMOD r AI IOUNT
Non-Water Supply Well: o tt f' 1401e fig pV $
❑hloniwring ❑Recovery 3 ft e7� ft 61C)c
injection Well: ft. ft
❑Aquifer Recharge ,� ❑Groundwater Remediation 19.uAi @/GRAYI.PACK(if ap liable)
❑Aquifer Storage and Recovery ❑Salinity Battler FPOr•1 TO MATERIAL lY=01)
❑Aquifer Test ❑Stormwater Drainage tL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neressa
FROM TO D2SCRIPTION color,hardnes soalrack q '°sae,eh.
[:]Geothermal(Ifeating/Cooling Return) ❑Other(explain under#21 Ramada) © 1 O ( y
4.Datc,Well(s)Completed: I a 1 Wen ID# -=.'S�aICJ
c ft ft
5a.wen Location: Phone '# 7�q=���•2(a3
ft ft.
C�.�i S t� (.,��i n �✓FacIti/OvmerName. FacilitylD#_(ifepplicable) ft. ft
fL ft.
FL fL
Physical Address, -d zip
21.RRMARKR
County e�I, Parcel!den ificatidn No.p1lq)
5b.Latitude and longitude in degrees/minutes/seconds or deans!degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): "Iermanent or ❑Temporary Signature 4f C d Well Contractor Date
t By signing this form,l hereby certify that the well(t)was(H,ere)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or Jqo 1SANCAC 02C.0100 ar ISA NCAC 02C.0200 Well Construction Standards and that a`copy
If this is a repair,fill out!mown well construction otformation and evIab+the nature of the, of thin record has been provided to the well owner-
repair under#21 remarla section or on the baekofthisform. 23•Site diagram or additional will details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having-the some You may use the back of this page to provide additional well construction mfio
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofweIls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: too.') (ft) Subit this GW-1 within 30 days of well completion
For multiple wells list all depths tfdiffawzr(=ample-3@200'and2@1001 m s w n a Y per the following:
'� ( )ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use N
f Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) Bit Off: � �Oy 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) - N
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal RetnraWells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county a onmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: UA
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,-CCPCU?
�+ Permit Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) J Method of test of a' j3 d e
13b.Disinfection type: 70%HTH Amount �� OZ DATE SITE VISITED:
VISITED BY: (�
,;s
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources l Revised 6-6-2018