HomeMy WebLinkAboutGW1-2021-05307_Well Construction - GW1_20210615 - _- - -1� `_.-, -- L -----------
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FROM TO DISC__ T_JO�jml Well ontractorN e 3,r- �,ctoft. J 61 9-4.5 NZI LL -
NC Well Contractor Certification Number
SDIG(for IiZ ed ells) R LINER(if le)
P 15.OUTER CA 1 0
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YADKIN WELL COMPANY,INC. TID _R r THICKNESS INTERLAL
Company Name I I
16.DWE R CASING OR TUBING(keritherinal dosed-loop)
2.Well Construction Permit#: FROM TO DIAJVIETER TEUCENESS MATERIAL
Variance,etc-) 51)A.) I
List all applicable well construction permits(ie.&7C,County,State, ft. // ft.
4' /3
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENrROM T UV.-HETER I SLOT SIZE I TMCKNESS HATERLU
DAgricultural DMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) Kesidential Water Supply(single) ft. ft, in.
01ndustrialiCommercial OResidedtial Water Supply(shared) -Fs-
.
01rrigation 0We1Is>100,000 GPD FROR11 TO NMTrRLAL EPUPLACEBAENT METHOD&AMOUNTNon-Water Supply 11i'elf: ft.
DMonitoring I DRecovery S
Injection Well: I
oAquifer Recharge I
00roundwater Remediation
19.5WIII)/GLFt, EL PACYK(if applicable)
DAquifer Storage arld'Recovery oSalinity Barrier FROM TO MATERIAL r, LACENEENTNMTHOD
J .
DAquifer Test OStormwater Drainage ft. ft
DExperimental Techni logy OSubsidence Control &
oGeotherrnal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
I FROM TO DESCRIPTION(color,hardness,sail/rock type,gmin size�ern
DGeothermal(Ileating/Cooling Return) ❑00ther(explain under#21 Remarks) it.
I e r IX 5d
4.Date Well(s)Completed: Well ED# A7
ft. ft.
5a.Well Location: Phone # /A r✓
ft. %
4��Aew 4/,a
ke-v i�k
Facility/Owner Name facility ID#(if applicable)
4V- t/
Physical Address,City,and Zip &
1, 1 21.REMARKS
'A C4
County 1 l Parcel Identification No.(PW
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlongis sufficient) 22.Certification:
7
L 6, N . q 171 W
6.Is(are)the well(s): Permanent or OTemporary Sign oe6fCertifiIieWell 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 existing well: 0Yes or LINO 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 exp la in the nature of the of this recordhas beenprovidedto thei4,ell owner.
repair under#21 remarld!section or on the back of this form. i
1 23.Site diagram or additional well details:
ir 8.For Geoprobenul I 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-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: ft
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a.For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casinguse"4"
11.Borehole diameter: (in.)
I Bit Off- 41.000 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method:
1 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 producing IoVer 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 15" Method of-10%HTH test-
13b.Disinfection type: Amount: Oz DATE SITE VISITED:
92
V16'ITED BY: -.2
Form GW-1 C North Carolina Department QfEn ffi Quality-Division of Water Resources Revised 6-6-2018