GW1-2021-05250_Well Construction - GW1_20210503

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Well Contractor Name Z3
3o36A '411 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-ciled;ivellsj OR LINER
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YADKIN WELL COMPANY,INC. FROM MATERIAL
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Company Name _T 2 3- 16.INNER CASING OR TUBINC(geother 21dosed-loo
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2.Well Consuction Permit#: P k LJ L.16 FROM TO DiAtvIETER TE11 110 0 7.Y.3 6 1
List all applicable well construction permits ri e.&7C,County,State, flarionce,etc.) + I ft- 91 ftin. I SPA VC
3.Well Use(cfeeck well use): ft. fr. I in.
17.3CREZN
Water Supp3y Well: L
DAgriicultural 13M al/Public FROT"i ft. TO DI-12JEETE-.1 SLOTSIZE TUIC19'[ESS rA
nicip ft.
DGeothernial(Heating/Cooling Supply) OM
Water Supply(single) ft. n.
olndustrial/Conimercial DResidential Water Supply(shared)
DIrrigation OWells>100,000 GPD rROP"I TO NIATEFLIAL EPAPLAM-M NT P.0-FTEOD&Ar,1010T
Non-Water Supply Well: 0 11. :? it. nde.164' 21.
Olvionitoring DRecovery
-3 ft- 2-1 ft- 8 mfh, 1"�'X Pu'-Plal
Injection Well: ft. ft
0Aquifer Recharge OGroundwater Rernediation R
19.SA11IDD/GRAVEL PAC LK(,�f3ppficnble)
DAquifer Storage and Recovery OSalinity Barrier FROM TO I ]VIATE-RdAL I EPJFLACE-N1-ENTII-r_,,THOD
OAquifer Test OStormwater Drainage ft.
DExperimental Technology oSubsidence Control -,-; i it
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
ElGeothennal(Ileating/Cooling Return) 00ther(explain under#21 Remarks)J FROld TO DESCRIPTION(color,hardness,sail/rock type ain size,etc.)
0 Ig ft -50"/ C&�'
4.Date Well(s)Completed: At-12--2-[ Wefl ID# ft' ft'
5a.Well Location- Phone #IJ-i v 2XC-ao'74 9-r ft' 1,"U-0 ft' Ac -
-0 IL ft..2r 6.,,A -1-14J r2V&,-dz
Facility/Owner Name Facility M#(if applicable) ft. ft.
N O Po'se ft.
Sg ft. ft.
Physical Address,City,and Zip I
3
9 4(0_0 I_+g_3 1 1 21.REMARKS I A ly 3 202i
County Panel Identification No.(PIN) iii�ar1;:.35,o11 P=essirio Wit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
30 2-54- 0 VQ N 40 17-A*6 32, 91919 W -.21
6.Is(are)the well(s): Ildermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certifythal'the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0yes or 94 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 well owner.
repair under#21 remarks section or on the bark 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 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 61 (ft I
Submit this GW-1 within 30 day&of well completion per the following:
For multiple wells list all depths itdifferent(example-3@200'and2@100D i
10.Static water level below top of casing: _ro_(ft) 24a. For All Wells: Original form,to Division of Water Resources (DWR),
Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"," i
C�_ _r' 9 24b.For Injection Wells:Copy t i Underground Injection Control(lUC)
Bit Off: 9 DWR,11.Borehole diameter: On-) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY 1 1
12.Well construction method: 24c.For Water Supply and Open!L6op 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) t:2z Method of test: r CL i r
U
13b.Disinfection type: 70%HTH Amount: 19 Oz DATE SITE VISITED:
VISITED BY:
North Carolina Department of Environmental Quality-Division Form GW_1 n of Water Resources' Revised 6-6-2018
PRICE ,