GW1-2021-05366_Well Construction - GW1_20211013

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NC Well Contractor Certification Number n021 15.OUTER CASDIG(for multi-cased wells)OR LINER(if applicable
YADKIN WELL COMPANY,INC. n C 1 L FROM TO DIA11•IRTER TffiCIQVI;SS TCRIAL
l' El�t ft. ft. in.
Company Name COOBSS
'(1� 16.INNER CASING OR TUBING( eothermal closed-loop) co
/� ,may � �i� t�cCCl�On
2.Well Construction Permit#: I(/ ���i�d I�`�'' FROM TO DIP.A'IET);R TffiQIQVESS MATERLII:"':.
List all applicable well construction permits(ie.UIC,County,Stale,Variance,etc.) /.! ft. -7� ft. (. F
3.Well Use(check well use): tt' ft. ft. ! in. i
Water Supply Well: 17.SCEs,E r C_Q
t FiiOil TO DIAMETER SLOTSUE TMCBMSS i:IATERial
❑Agricultural I ❑Municipal/Public fr. ft. in.
❑Geothenmal(Heating/Cooling Supply) kL,esidential Water Supply(single) It. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ag GROUT
❑Irrigation ❑Wells>100,000 GPD rROP/I I TO WMRLAL E•LaLACEP'1=tiT IY2T50D&AJ1,10WiT
]Von-Water Supply;Well: oft. ft. ,�� ✓ �)
❑Monitoring j ❑Recovery ft. ��. � oipC�
Injection Well: 0aef
ft. ft.
❑Aquifer Recharge I ❑Groundwater Rernediation
19.SAPIID/GRAVEL PACISWa plicable) ��+
❑Aquifer Storage and'Recovery ❑Salinity Barrier FROM TO PIATERIAL ENIPLACENI-Ei'1T ntETHOD
❑Aquifer Test j ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessa )
❑Geothermal(HeatinWCooling Return) ❑Other(explain under#21 Remarks) 6)FR To DESCRIPTION color,hardness,soiurocic a rain sae etc
i (� ft Lel ft. Sp
J r
4.Date Well Completed: /'L- �( Well ED# �t0� ft opf
8� ft e�
5a.Well]Location: Phone #Rj P`� 3 l 3� aft /a v ft
rs. S�A h 6 e Ly-h�a r t GY'. 60,0 ft. �r d ft. -
f Facility/Owner Name ``� V Facility ID#(if applicable) `JOV ft.
$o. A All
fL ft.
fL
Physical Address,City,and Zip �� ` ft
21.BE,
County. / Parcel Identification No.(PIN)
�'• Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i (if well field,one latAong is sufficient) 22.Certification
3 N S66 Sa, 3 £f3 w
! Si o Cettifi ell Contractor ate
6.Is(are)the well(s):' Permanent or ❑Temporary
By sign hg this form,I hereby certify that the well(s)was(were)constructed in accordance with
ed 7.Is this a repair to an existing well:' 0Yes or�0 15A NGAC D2G.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
o this reco ltos been provided to the well owner.
If this is a repair,fill out known well construction information d explain the nature of the f
repair under#21 remarks!ection or on the back of this form.
23.Site diagram or additional well;details:
9.For Geoprobe/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 1 GPJ-1 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
i
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(r)20 'and 2@100)
1 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7®� (ft) formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: 24b.For Injection Wells:Copy'to DWR,Underground Injection Control (IUC)
11.Borehole diameteI: (in.) � Program,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
(i.e,auger,rotary,cable,wt push,etc.) county environmental health department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
1 . , Permit Program,1611 MSC,Raleigh,WC 27699-1611
13a.Yield(gpm) S Method of test: Q/ ✓ kG� "01.
t 0 DATE SITE VISITED:
13b.Disinfection type: 70%HTH Amount: �®. OZ I/
VISITED BY: /.1►
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
fPRfCE ! V. {SZ.�' (Zap9- peel-1