GW1-2021-04218_Well Construction - GW1_20210415

nv; r"�t�s1�T� ii�Jti P�RECORD,(G VI i, For Internal Use Only:
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14.IVAaER 70fil
FROM TO DESCRIPTION
Well Contractor Name
ft: I`7©' ft. 36 V t4M
P, �, ,
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedllvells)OR LINER if ap licable
YADKIN WELL COMPANY,INC. 202� FROlyI TO DIAl1•IETER THIMr_, MATERIAL
ft. tt. in.
Company Name V r n ee.Siri. Uilii 16.INNER CASING OR TUBING eothermal closed-loa
�� �'�' FROM TO DIAIYIETER THICKNESS MATERIAL
2.Well Construction Pei mit#: 3 3 ft. �� ft. G 0/ i"' S RaI VC
List all applicable well construction permits fl.e.UIC,County,Stale Variance,etc.) 4-1
ft. ft. in.
3.well Use(check well use):
17.SCREEN
VJa:e➢ Supply well: FROM I TO
DIAME,—MR SLOT SIZE I THiC194ESS NIATERI1L
❑Agricultural ❑Municipal/Public ft. ft. in•'
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) `:.,ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 13RO IT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL ENT METHOD r1 APr10UNT
Non-Water Supply Well: 0 ft. AQ ft. HDk, PIJ POvfej °°Q 6q83
❑Monitoring ❑Recovery L� ft• h 'I 6r,-A Pv
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To IA NIATERL EivIPLACEIYIENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional"sheets if necessary)
MON TO DESCRIPTION(color,hardness,soil/rock e, rain sizq etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:_31II I Well ID#1Ti`f�' ! y� �, ft. Ct. G o
ft. ft.
5a.Well Location: Phone # 8J,3 I��s"773
/ ft. ft.
rD h h 6—t-0 S it A/e t- ft. ft.
Facility/Owner Name J Facility ID#(if applicable)
r ft. ft.
o��i�T 14'G/G/r 1 Q e S>! �G: ft. tt.
Physical Address,City,and Zip
21.REMARKS
b(_)q (,A w
County U Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latAong is sufficient) 22.Certification:
N Fy 1 S, 73 RO w
Q a!L4 °
6.Is(are)the well(s): Xpermanent or ❑Temporary
Signat4re of Ce.tified Well Contractor Datel
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑yes or1Qo 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a copy
this is a repair,fill out known well construction information and explain the nature of the of this r ecord has been provided to the well owner.
If
repair under#21 r•ernorks 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-1 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: U � (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdierent(example-3@200'and 2@100D
4 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ©U (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Bit Off: 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
(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 producin I over 100,000 GPD:'Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: C'L c
70%HTH �a OZ DATE SITE VISITED: 3 i��•�
13b.Disinfection type. Amount:
y V Si H A co- 1 ��lsl lox /111 VISITED BY: l/V3
Form GW-1-J J V JNorth Carolina Iepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018