GW1-2021-05263_Well Construction - GW1_20210503

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Well Contractor Waine r TO DZ5CP_-' T JON
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NC Well Contractor Certification Number PCO15.OUTER CASING for multi-MET ivells)MMRAfapqliWI
YADKIN WELL COMPANY,INC. Jr1j0fJr.3t-"OT1 FROM I TQ_� DLAMETER T1 RLAL�-
Company Name C-c>
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To MAXI r•.R TEaCKNrSS MATERIAL
List all applicable well construction permits(k a.UIC,County,State, Variance,etc.) ft % -r/Of in. a I
g ,.
3.Well Use(check well use): t. C ft in.
Water Supply Well: 17.SCREEN SLOTSIZE I THICIGiESS I HATERIAL
Pylord TO DIA?JETER
CAggicultural 0 nicipal/Public
DGeotheripal(Heating/Cooling Supply) 19 e�tesidential Water Supply(single) ft.
DIndustrial/Conim-ercial DResidential Water Supply(shared) I&Gr'QUT
OIrrigation DWells>100,000 GPD FRO11.1 - To MATERIAL ENIPLACEAUHTNMTHOD ASKOUNT
Non-Water Supply Well: v P. ft.
DMonitoring ORecovery 3 ft.
Injection Well: - 9- /Vfq RUMOU
'2 q ft 1/644te,
OAquifer Recharge OGroundwater Reinediation
19.SATITD/GFUIVEL PAC (ifapplicable)
OAquifer Storage and Recovery ❑oSal�ity Barrier FROM TO MATERIAL Er.rPLAc:-:rwimVTAlETHOD
DAquifer Test EIStormwater Drainage
OExperimental Technology oSubsidence Control ft.
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessaeta
ry)
DGeothermal(fTeating/CoolingReturn) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,Min size,
0 ft. ft. C/4
4.Date Well(s)Completed: 'q- Well W#1460-YY7 E/
52.Well Location: Phone #
ft- 'L//J- ft-
Facility/Owner Name Facility ID#(if applicable) Wo S-A/- (;
C 2-a 12 el K i, 6�,//f A o r eq-q 4 1/6/0 Eva. fr. Hal GraA1,41-
Physical Address,City,and Zip ft. ft.
2 1.RE,AIARKS
cltnq
County 11 Parcel Identification No'(P]N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweH field,one lat4ong is sufficient) 22.Certification:
3C' OJ_ -I'T9 N `7 9.0 0a- :2, 7 W YlV46-
6.Is(are)the well(s): germanent or OTernporary Signature of Certified Well Contractor Date
By signing this fo
rm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or 8No, 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a reppirfdl out known well construction information and explain the nature of the of this record has been provided to the wel:I owner.
repair under 921 remarks.section or on the back of this form. 23.Site diagram or additional well details:
8.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 G'-I 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: q cz, (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D
24a. For All Wells; Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Xb (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: (in Bit 24b.For Injection Wells:Copy to IDWR,Underground Injection Control (IUC)
16 Program,1636 MSC,Raleigh,NC 27699-1636
i
12.Well construction method: AIR ROTARY 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) .2 Method of test: ir Permit Program,1611 MSC,Raleigh';I NC 27699-1611
13b.Disinfection type: 70%HTH Amount: a-0 Z DATE SITE VISITED:
VISITED BY: A
qForm GW-I North Carolina Department of Environmental Quality-Division of Water Resources evi sed 6-6 2018
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