GW1-2021-05312_Well Construction - GW1_20210615

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Well Contractor Name ��- FriCr.I TO
- � �� uniiNE
303GA ;ae�c ��ila�7 ft. / fr.
NC Well Contractor Certification Number iOSOin'0`' t;�CC`t100 15.OUTER CASING for multi cased ieells OR LINER Rif applicable 0.
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YADKIN WELL COMPANY,INC. FROM To DIAAW ER CIMS5 TERTAr.
Company Name e- 16.INNER CASING OR TUBING(' otherma]closed-loop)
2.Well Construction Permit#`'-SMF 0 I I - FROM To DIANETrR TH1a0Ess MA-LEMAL
List all applicable well construction permits(Le.117C,County,State,Variance,etc) fr fr• ( ' 1°' SDIR -21 1 JOV
3.Well Use(check well use): fr• ft in.
Water SuppV Well: M SCREEN
t'I?Oivi TO DU�dIET'e? I SLOT s12E J=3S I P:InTLP.i-�.
❑Agricultural ❑ unicipal/Public ft. irk•
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr. in C
❑1ndustrial/Conmmercial ❑Residential Water Supply(shared) 18.GROUT N
❑Irrigation ❑Wells>100,000 GPD FROM TO PMTax1AL Et-IPLACEP.MNT METHOD r.Alr10UNT
Non-Water Supply Well: 0tt. 3 ft
❑Monitoring ❑Recovery ft. ft11MZ65L4
S Q 3
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.uAl`fIb/GRA'%rl:L PACK(if appficable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEIML I EAULACE,r.-MIT METHOD
❑Aquifer Test ❑Stormwater Drainage fr
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Meating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DL�sCR1PTION color,hardness,aoil/roc4 rain size,erg
A A c 1d fr. fr.
4.Date Well(s)Comp leted:S-ez-5'.2 L Well D#,4,46 v- 2 s fr (� fr �f ' p kp .s
Sa.Well Location: Phone # 3�' 9nJ�:T arc ft ft � &rCI
Lyt s ft fr.
Facility/Owner Name Faciliitty/ID#(if applicable)
. ') �-y:S ���D S �t�. !e►Lf�f lA v e [r �7f) ft s.
Physical Address,City,and Zip ft. ft
1 21.REMARKS
yc kr tom;
County ; Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lai/long is sufficient) 22.Certification:
3LO 5711 N C' qq ( 0 W e .s"- aS -�(
n� � �
6.Is(are)the well(s): W/.anent or ❑Temporary Sigaatue of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eristing well: ❑Yes or 94o 15A NCAC 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 of this record has been provided to the ivell owner.
repair under#21 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 1 is needed. Indicate TOTAL NUMBER ofwells (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: 0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdiffema(example-3@200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Jr" (R•) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
i Bit Off: �� q 31 24b.For Ilriection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�) 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
(ic.auger;rotary,cable,d rect push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin>i over 100,000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) Method of test: o,),r
u �D DATE SITE VISITED: 4
13b.Disinfection type: 70/e HTH Amount: OZ
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
PkICE : C)r_11