GW1-2021-04227_Well Construction - GW1_20210415

lLiLl'i�TSriloJ I J C.y �i+ �� �tl�:f ��`iI-1 For Internal Use Only:
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1.Weld'Coy r•ractor iin.'iorrnaraon: '
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f rl •,� "'" 11.avATEI3 aD1S l
A:4' Well Contractor Name 5' ...m FROM TO DESCRIPTION
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� ft. 6 Go ft. 1 s PM
�,�� 5) 2021 ft. 190 ft. 3,j GPrn , n
NC Well Contractor Certification Number 15.OUTER CASING for lti-cased wells)OR LINER if ap licable 1
YADKIN WELL COMPANY,INC. �oidvili':�E•s011 � ^L rolltL)1Z FROM TO muDIAI\IETER THICKNESS MATERIAL
ft. ft. in.
Company Name V V- v d v
16.INNER CASING OR TUBING&othermal closed-loop) ^
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL C
List all applicable well construction permits(i.e.UIC,Counnty,State, Variance,etc) + 6 ft. 5-7 ft. f/ in. �® � pvC
17.SCR
3.Well Use(check well use): E ft. in.
' SCREE �r
Water Supply Well: FROM TO DIAMETER SLOT SIZE TH€CKNESS MATERLAL
❑Agricultural ❑Municipal/Public it. ft. in.
❑Geothermal(Heating/Cooling Supply) 'Ntesidential Water Supply(single) ft. ft. in. C/
❑Industrial/Commercial ❑Residential Water Supply(shared) lil GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EhIPLACEMENT METHOD&AMOUNT
Nora-Water Supply Well: it. 3 ft. 1401C PAN POOTO 41 I/
❑Monitoring ❑Recovery 3 ft. ?q ft. t t 6 Putupeda
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EI!•IPLACENIENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soittrock• e, in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ® ft. j„ •7 ft. l '
nn /n���11 / � tf
4.Date Well AA6s)Completed: �� Well ID# d "I I 4 -7 ft' ?04 ft. ke
a
Sa.Well Location: Phone # 4o! a- 73�- 1'3$G
Cl� 5 t lX.kLC `I-a l l ik ft. ft.
Facility/Owner Nan a Facility ID#(if applicable)
�? q 5- E i` S^,;- Elk. J�6.21
Physical
Address,
City,and Zip
U 11 r 21.REAIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
(� © ft�, �`�1 N 0� , ;y . �Gll W
.,L a
6.Is(are)the well(s): �fermanent or ❑Tempo ary Signatur ofCertijbd well Contractor Date
CCC �" ` / By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �\_ 15A NCAC 02C.0100 a•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 well owner.
repair tinder 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 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: -y 24.SUBMITTAL INSTRUCTIONS
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 if different(example-3Q200'and 2@700)
d (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" /
11.Borehole diameter: IP (►n•) Bit Off: /A.b(!I 24b.For Injection Wells:Copy to DWR,Underground Injection Control (JUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and OpenLoop 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 producinglover 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
%13b.Disinfection type: 70%HTH Amount: '/� OZ DATE SITE VISITED:'
3a� �1
VISITED BY: A°* Is 3 D�0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018