GW1-2021-05459_Well Construction - GW1_20210615

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FROM TO DzSCrL�IOit
Well Contractor Name ' d�� 1s^
�r TIM
ft. .a3 GocPf"
0 (�-1�l o� 9 ft. ft.
NC Well Contactor Certification Number ,1`j 1 T_ �O� r
15.OUTER CASING tar multi-cased wells OR LINER if a plicnble
YADKIN WELL COMPANY,INC. n�S;lr`�ljy�li FROM To DIAAMTER; THICIQVESS TERIAL
t�f^.L
ft, ;in.
Company Name �`y;f�`a^',vl;r'il ft. �
d 16.INNER CASING OR T[JBING( 'othermal dosed-loop)^�
2.Well Construction Permit#: 0DF{9 FROM TO DIALMETER` THICTM.SS MATEERIAL
List all applicable well construction perffi its(.r-11IC,County,State,Variance,etc.) Jj fL U D ft /Y I in 509,)l C,,
3.Well Use(check well ase): ft. ft in.
17.SCr�£ i l
Water Supply Weil:
FRord TO DUAIETLR: !.SLOT SIZE TMCHNESS i••IATf RIAL
Pgricultural Ca G rt e,, ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooliug Supply) ❑Residential Water Supply(single) It ft. in.! Cs
❑Industrial/Conunercial ❑Residential Water Supply(shared) 111.GROUT Cs
GIrrigation ❑Wells>100,000 GPD, FROnf I TO P TERIAL E:4PLACE&LNT PM TROD c A.r.ioUNT
Non-Water Supply Well: it. 14, ft' I tole Put oural 4 104 33_
❑Monitoring ❑Recovery l r F• ' fi (2 u IC K 6rou Nv ftj LS 114 4.3 S r
Injection Well:
ft. ft. �
❑Aquifer Recharge ❑Groundwater Remediation
.19.SAP@/GRA1r ,L PACK(if applicable)
[:]Aquifer Storage and Recovery ❑Salinity Barrier FEOM TO IYIATERi L I EBPLACEP.M41KhLl On
❑Aquifer Test ❑Stormwater Drainage ft ft i
❑Experimental Technology ❑Subsidence Control % ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attacb additional sheets if necessa
❑Geothermal 04eating/Cooling Return) 00ther(explain under#21 Remadm) PROM TO Dl�SCRIPTION color,bardarss,coiUrodc i°saq etc.)
^� tt U ft. ft
4.Date Well(s)Completed: S 13( (31 Well. `T 40 r i�OO S fitt. 183 ft G roe% ! -
C OV,, one #33�=3�'��Q�� . �'T
5a./WeeJll Location:
Facility/Owner Namtf Famlity ID#(if applicable)
Physical Ad ess,City,and Zip ft ft
S wY`in y 2L REBIAP c
County Parcel Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '4N
(ifwell field,one lat/long is sufficient) 22.Certification:
N W 5 a6�•�� (_
6.Ls(are)the well(s):Aermanent or ❑Temporary Sipatarb ofCmifiedWill Contractor Date
Bysigning thisform,I hereby certify that the well(s)was(were)conducted in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform- G
23.Site diagram or additional well details: r
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 GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: p 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: o, (ft) Submit this GW-1 within 30 days of well completion per the following:
For mudttple wells IW all'depths ifdifferent(example-3©200'and 2@100) t
�0 (ft) 24a. For All Wells: Original foim to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use C
r. Bit Off: �1 I 1 24b.For Infection Wells:Copy toDWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
f
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,duect push,etc.) county environmental health depa
r
t
nent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinEover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)
Ls Method of test: jR,A k Pemnt�Oir�'1611 MSC,Raleigb,WC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: ! i
i
�G� a VISITED BY:
Forty W-1 s._ North Catlglina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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