GW1-2021-04216_Well Construction - GW1_20210415

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For Internal Use Only:
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'Well Contractor Name TO DESCRIPTION
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NC Well Contractor Certification Number 2 i
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CASING for multi
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AMETER
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15.OUTER CASING(form ulti-caged i ID
YADKIN WELL COMPANY,INC. FROM TO lillal RIAL
Company Name
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6.JINMER CASING OR TUBING(geother alchised-l'
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2.Well Construction Permit#:.. 7 Y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constniction permits(i.e.UIC,County,State,Variance,etc.) I`- ft. I in. q
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ft. ft
3.WeN Use(check well use): ft. ft. in.
Water Suppiy Well: 17.SCREEN
FRONT TO DLAIMETER SLOT SIDE THICKNESS WATERIAL
ElAgricultural OMunicipal/Public ft. ft. in.
DGeothen-nal(Heating/Cooling Supply) Residential Water Supply(single)
01ndustrial/Commercial DResidential Water Supply(shared)
18.GROUT
01rrigation DWells>100,000 GPD FROM TO MATERIAL EMPLA.CriVlEi'iT&JETHOOPATITOTIPIT
Non-Water Supply Well: ft,
3
DMonitoring ORecovery
Injection Well: 3 ft- 9 14 ft.
I B!"J'."4
ft.
OAquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PAC (if aiiplichble)
OAquifer Storage and Recovery CISalinity Barrier FROM TO I MATERIAL END? ACEMEKT 11-LETHOD
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control ft.
OGeothermal(Closed Loop) ElTracer 20.DRILLING L (attach additional sheets if necessary)-
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) rROA1 TO DESCRIPTION(color,hardness,soil/rock type, in size,etc.)
o ft.
4.Date Well(s)Completed: Well ID# 14e40
5a.Well Location: Phone # g2g_'7Z3_agg 1-114 6f,,41- 4 Zlbi'4 Ad-Clk
13 lit'1Y
Facility/Owner Name Facility D:)#(if applicable)
N/t16X 'gral"I Rao /Solo H sft.
Physicai Address,City,and Zip ft. ft.
7S L-t I A- 21.REMARKS
5 2021
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n
(if well field,one lattlong is sufficient) [TiiV i.'� S�l U I I J
22.Certification:
3 N X1 3,,S', 0'31q W
12- .2
6.Is(are)the well(s): 1Permanent or OTemporary Signature Certified Well Contractor i Date
By signing thisforin,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or 90 15A JVCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair tinder#21 remarks section or on the back ofthisforin.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You�may also attach additional pages if necessary.
drilled: - 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 6 .Z --(ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form!to Division of Water Resources (DWR),
7
Ifivater level is above casing,use Information Processing Unit,1617 MSC,1 Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 6, 24b.For Injection Wells:Copy to DWR, Underground Injection Control(IUC)
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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(gp-) Y' .IU Method of test: ef Ali- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: fl oz DATE SITE VISITED:
VISITED BY:
Form GW-I &fiJ&lina Department of Environmental Quality-Division of Water Resources i I*Revised 6-6-2
51A, 018_