GW1-2021-05314_Well Construction - GW1_20210615

-.7 "ternal Use On
L, 1-1.%NAJ_7R Z&i,rE
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FlION TO DESC11,2Tior)
Well Contractor Name ft. - ft.
I Jor), .uc - rf
303 " JUNI 5 2021 171 ft. 17:z ft.-:O�- :
NC Well Contractor Certification Number lnfbrmat>on Prow.ssing Unit 15.OUTER CASING for multi-c0se&WElls) lle
if app'iMATERIAL LINER 0�!L% I1
1
YADKIN WELL COMPANY,INC. DIUR Sedon FROM TO T DLUCTM F T11
Company Name
tcu&I?1 i v- 3.76-Fr Y-9- 7 qJ Jr A.INNER CASING OR TUBING(geother al dosed-loop)
2.Well Construction Permit#: K I S&t: 011 Jt Y 7Z I FROM TO DLAMTER THICKNESS r"TERML
List all applicable well construction permits rie.WC,County,State,Variance,etc.) 4, 10.2 ft. 4. A
I3.Well Use(checIc well use): ft. in.
17.SC!tE:-:N
Water Supply Well: FROM TO DIVUdETE SLOT SUE TUICHMESS R I
DAgricultural oMunicipaUPublic ft. ft. in.1 P.-U-TERLAL
:57
DGeothermal(Heating/Cooling Supply) ),Residential Water Supply(single)
01ndustrial/Commercial DResidential Water Supply(shared)
iL9.GROUT
DIrrigation DWells>100,000 GPD FROPA TO EMPLACEMENT METHOD tVIOUNT
Non-Water Supply Well: f". 3 . ft.
DMonitoringa ORecovery ft. _24/ ft.
Injection Weil:
oAquifer Recharge oGroundwater Remediation V1,kCe,
13.SAND/G L PACK(dariplicable)
DAquifer Storage and Recovery DSalinity Barrier FROM TO TYLATERIAL ED1PLACEP/rENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach atWitional sheeE if necessary)
DGeothermal(Ileating/Cooling Return) 00ther(explain under#21 Remarks) rROAJ TO DESCRIPTION(color,hardness,sailtrack type,grain size,etc)
C) ft. 7 IL
4.Date Well(s)Complete&Y--7 S'aWell ED# AX 6 -S3 0 73- fL fL
5a.Well Location: Phone # 334-(of,2-b TP OS eO ft' 16 fL AU S-eA--"x 4-
5/1 ft lr!,E ft. ,?NZ fL Yvd 6,4,jf e-
Facility/Owner N&e Facility]D#(if applicable) ft. ft.
%T ( 4 d ft. ft.
r 02S 1ha
Physical Address,City,and Zip ft. ft.
va wokf-Al 21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N 6 3 W Of
Tature
6.Is(are)the weIl(s):.Permanent or OTemporary §i; of Certified Well 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: DYes or A90 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 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: 0? 1/ J., (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells IW all depths ifdifferent(example-3@200'and 2@1 OOD
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 casing,use"+11
11.Borehole diameter: Bit off: b i 0 fl 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUQ
Program,1636 MSC,Raleigh,NC 27699-1636
1 1
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 producing o I er: 100,000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) /0 Method oftest: q,,rx, Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED-
Al IS* T9 VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018