GW1-2021-05271_Well Construction - GW1_20210503

J. -7
-L, L
-7 Z
FROM TO D C Mi I
Well Contractor NameNk A-9 2
3 03 � A V,
NC Well Contractor Certification Number 15.OUTER CASPIG for bd,i7eII§)OR LINER 'e(ifapp'i*
YADKIN WELL COMPANY,INC. FROM TO MATERIAL
Company Name 16.RIDIER CASING OR TUBING(Leothermal dosed-loop)
2.Well Construction Permit#: 14/15,m 0!�-:- 0i I�j FRO", TO MWIETER THICKNESS MATERML
List all applicable well construction permits(Te.Ult,County,State,'Porionce,etc.) ft- S-q ft. in- Sjt-a, FuC
ft. ft. in.
3.Well Use(check well use): 17 ft
17.SCIU-Z N
Water Supply Well: FRor-11 1 *ro SIZE
DT-WAETER SLOT 1Z TE-1cMiEss NIATEPLAL
DAgricultural DMunicipal/Public
OGeothermal(Heating/Ccoling Supply) KResidential Water Supply(single)
01ndustrial/Commercial OResidential Water Supply(shared)
J&C-ROUT
01rrigation OWells>100,000 GPD TO EPIPLACTF.-M,HT PdETHOD&A0.101JI11T
Non-Water Supply Well:
oMonitoring ORecovery I ft- .20 41 ise;,21d -T
ft. '99
Injection Well:
OAquifer Recharge OGroundwater Remediation
OSalinity Barrier FROM TO,� MATERIAL Ep"LPLACELTERT rM TEOD
19.SANO/GRAYE L PACK(if applicable)
OAquifer Storage and Recovery
DAquifer Test oStormwater Drainage
oExperimental Technology OSubsidence Control
ElGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Ifeating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION IPTION(color,h.ardness,soillrock type,grain size,etc.)
o ft- 7J- spj/
4.Date Well Completed: 41-1-r-Zl Well ID#AA0-f(e/3 -7 r ft. .2 io ft. so 6 ge,
5a.Well Location: Phone 2 70 It' 3CZ
ft.
Facility/Owner Name Facility M#(if applicable) fr'
3 a tiltr- ft. ft. r-�c
Physical Address,City,and Zip
21.REMARKS
4 k'A7
Coun Parcel Identification No.(PIN) 0110
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification'
N
6.Is(are)the well(s): Permanent or OTemporary %nature of Certified Well Contractor Date
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: OYes or $NO 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 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 pagle 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: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells IW all depths if different(example-3@200'and 2@1001
1 water level is above casing,use Static water level below top of casing:0. 60 (ft') 24a. For All Wells: Original form to Division of Water Resources (DWR),
lf Information Processing Unit,1617M, SC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 6. os A" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and OpeniLoop Geothermal Return Wells:Copy tothe
(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
13a.Yield(gpm) Method of test- a,, Permit Program,1611 MSC,Raleigh,NC 27699-1611
I
13b.Disinfection type: 70%HTH Amount:A L/ Oz DATE SITE VISITED: 3 -.:1;
pe 'f H VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 3T2, Revised 6-6-2018
6