GW1-2021-05466_Well Construction - GW1_20210615

•__, ,=7L1L ®N1S7C JTCA]f!(DN RECORD(GW-A) For Internal Use Only:
1.Well Contractor Information: RE-CENED
Well ContractorN e U; ; FROM TO DESCRIPTION
/ oft 3 ft. 3 ram.
�57�_A Irformaiicn Pro ssing U 1 /7)-ft 77 ft S7 �, ,,K S
NCWe1lContractorCertifieationNumber DI" R Section
� -15.OIITE12;"CASING formvlti=ce's `veDs'ORL•INER'ifii 'es1i1 ':
Yadkin Well Company Inc. FROM TO DIAMETER T�cc>nvsss MAnMIAL
ft ft. in.
CourpanyName �I'q��t�
'q ••:16:Ilvf7F,'R CASal•Gr01t TUBING -co`t1ii:�a1 closed Ioo "•<.-:•- •.-
2.Well Construction Permit#: Ili;44l: In(.� l`I1 Zal-I FROM TO Dl&ld rRz TTarCENF.sS ••.MATERTAT.'
List all applicable well construction permits#.e,EUC County,State,por once,etc.) / it ft 1;4" p�-� PvG
3.Well Use(check well use): ft ft in. !� r
rW. AEricultuml
pply Welk '17.•S(REEN:- __ '. i. r• :: . .
FROM TO XAASM. SIAT STLE TRICENESS MATERIAL
ural nMunicipal/Public ft, imi
al(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.1/Commernial [OResidential Water Supply(shared) GAOD 'n FROM TOEryBIACKDdE TMETHOD&AMOr Supply Well:ng [Recovery !i fL
Injection Welk 7 t My, r�
_ Aquifer Recharge D Groundwater Remediation ft.
Aquifer Storage and Recovery 08 Barrier = �IGRAVEL"PAG+IC rf "Iicable
"' -'J FROM TO MATTiRTAT. .E�pj,� I•ME7•$OD
--Aquifer Test �StarmwaterDiainage ft r-
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTiaeer 20;DRIIS7TTGLOG"attack'adgitiaiislsheetifaecrss" _
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remadrs) FROM To DESCRIPTION(mlanhardeess,saWnek p e �eiz
A �( 7 f ,11 o� odlc
4.Date Wells)Completed: .5-/7-a�Wenm#AAA —JY 7 ft •ft 179Lv -
Sa.Well Location: Phone num ft-ber l(BOft T� vac A�
Faty cili//Owner N Ee Facility M#(if applicable) ft. ft
e / �/JFQ ` `e ft
Physical Address,City,an Zip ft ft �^
y�.=i �t�' .21:RF.NTARKC ' _ ...L•
County Parcel Idcatification90.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fm1d,one Waag is sufficient)
22.Certification:
N W lliy(�1
6.Is(are)the well(s) Permanent or Temporary o Ce W Contractor Date
By signnng this form,1 hereby certify that the well(sJ was(here)constructed in accordmrce
7.Is this a repair to an existing well: ©Yes or +To with 15ANCAC 02C.0100 or IM NCAC;02C.0200 Well Construction Standards and thar a
Ifthis is a repair,fill oul known well construction information mid explain the nahae ofthe copy ofthis record has been provided to the' well owner. ^
repair under 421 remarks section or on the back of this farm. 3�
23.Site diagram or additional well details: r
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well �p
construction,only I GW-ls needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lint all depths ffdifferent(example-3Qa200'and2@100) construction to the following.
g
f Static water level below top of casing Y (ft) Division of Water Resources,Information Processin Unit,
lei-1 is above casing,use"+"lfwater
1617 Marl Service Center,Raleigh,NC 27699-1617
1L BorehoIe diameter: (in.) Bit Qom_ 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Xt r ��d
above,also submit one copy of this form within 30 days of completion of well
5/ lio
(Le.anger,rotary,cable,dimctpusb,etc.) construction is the fo wog:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a Yield(gpm)_ V _Method of test .! ,JA 24c.For Water Snvuly r$Iniectioni Wells: In addition to sending the farm to
H 1 H ed? �J 2 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: O I / a completion of well construction to the county health departm of the ty
where constructed �I Ve�y 1�T 9 d�
®; /�-Z1
Form GW-1 North Carolina Deparf rent ofEnviM==,ttaai Quo4-Division of Water Resources ` v Revised 2-22 2016
i�te Site Vis>f; l +.+1•.
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