GW1-2021-05251_Well Construction - GW1_20210503

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Well 6.—.t..tor N ie FROM TO DESCRIPTION
Certification Number t. dzo 1" 1 4K
NC Well Contractor Certif "7JC
�y 'I
15.OUTER CASPIG(fo multi-cas6kv�fells)OR LINER(if applicable
I LA,
ft. ft. in.
YADKIN WELL COMPANY,INC. �i �To— DIANIETER
I I THICICNESS
Company Name
16.INNER CASING OR TUBIPIG(geothermal dosed-loop) �57
2.Well Construction Permit#: Piz we— 2 n C-24 C3 4/.Os- FROM TO DLaAvEcTrR TMCKNESS --F—MAT-PRIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. k 4^ �• I A<,
3.Well U ft. ft. in.
Ilse(check weli use): I
Water Supply Well: 17.31CFEEN
FROPI TO DIAP.JETER SLOT SIZE TUIC-19IFSS HATERLAL
DAgricultural OM mcipal(Public ft in.
DGeotliermal(Heating/Cooling Supply) 12elsidential Water Supply(single) f
En.
DIndustrial/Commercial DResidential Water Supply(shared) -T8—GROUT
. OUT
DIrTigation DWells>100,000 GPD FROM - TO �MTERIAIL RNIPLACUIEJ IT METHOD&A1,10UHT
Non-Water Supply Well: ft.
0 ?A /,-Lft-/—�� 3 -4a--
0monitorin.- CRecovery I
3 ft or
Injection Well: IF -5/
oAquifer Recharge DGroundwater Remediation
19.SAPIDL/GRAWE L PACK WaDMicable)
DAquifer Storage and Recovery OSaliriityBarrier FRONI I TO I MATERIAL EPIPLACENME NT ADET HOD
DAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology DSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Heating/Cooling Retain) 00ther(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness,soillrocic type ain size,etc.)
D ft. 7.L!L C5 Q�4
4.Date Well(s)Completed: Well][D# -7 1 ft- 4;077- 4
//a 0 ft-
5a.Well Location: Phone cf200 Of'- ?
q C t
ft. ft.
Facility/OwnerSTame Facility ID#(if applicable)
62-o /-,-tier' , S'c-AaA Ref E4&,4 R!a to d
ft. ft.
P,F:("'.I P--I V
Physical Address,City,and Zip ft. ft.
SC4 P-I-y 21.REMARKS 7n?l
County Parcel Identification No.(PIN) !I
5b.Latitude and longitude in degrees/minutes/seconds or decimid degrees:
(if well field,one lattlong is sufficient) 22.Certification:
:?Cu 21, S-06 N �' s-/, -72o W
6.Is(are)the well(s): dermanent or OTemporary SiVKofCV&Well Contractor Date
By signing thisform,I hereby certify that the well(q)was(were)constructed in accordance with
7.Is this 2 repair to an existing well: Dyes or 14 15ANCACO2C.0100or]5ANCACO2C.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 V1
construction,only I GW-1 is needed. Indicate TOTALNUNSER 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:
For multiple wells list all depths if different(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: 24a. For All Wells: Original fo Ito Division of Water Resources (DWR),
lfwater level is above casing,use A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.) Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27690-163 6
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department'rofthe county where installed
FOR WATER SUPPLY WELLS ONLY: ! i
24d.For Water Wells Producing ovir,100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ?-C) Method of test: /I,( W Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611
/A I
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: ^22 121
VISITED BY: I
Form rTW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6- 18