GW1-2021-05317_Well Construction - GW1_20210615

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NC Well Contractor Certification Number 30 7
jrjjofM.31�01 POsessm unit 15.OUTER CASING for multi-cased
L R ifaPTIV YADKIN WELL COMPANY,INC. Sef_-^eon FROM I TO DUAMTEP M=Ek applicable
ft. fr. in.
Company Name 3 36, 7 90y I — -
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: PV-31�17- FROM TO DULNECTER I TMCIOESS I MATERIAL
List all applicable well construction permits(Le.UIC,County,State,T'ariance,etc.) P ft. S- ? ft. < '�-31A pilc-
3.Well Use(check well use):
Water Supply Well: FROM TO_ DI-10JETER SLOT SIZE TOCI44ESS RIATULAL
DAgricultural unicipaUPublic ft. ft.
DGeothennal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Mdustrial/Corrimercial OResidential Water Supply(shared) 10.GROUT
DIrrigation DWelIs>100,000 GPD FRONI TO HATEMAL EMPLACEAME NT NIETHOD C AP.-IOUNT
Non-Water Supply Well: 0 f". IL/ ft.
omonitoring ORecovery Jq it.
Injection Well: ft. fL
OAquifer Recharge OGroundwater Rernediation
19.Si-UqD1GPLA1rTEL PAC (if applicable)
OAquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACETVIENT ATE THOD
OAquifer Test DStorrnwater Drainage ft. ft.
ElExperimental Technology OSubsidence Control ft. ft.
DGeothermial(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
1 0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etr-)
4.Date Well(s)Completed: 4/-�J Well ED4AAG- 40 ft. ft. 5
t-17 A�Iya f)- AJ S 7b-4-
5a.Well Location: Phone #3A- 2-)Ot-flikz
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft• ft.
Physical Address,City,and Zip fL
Physical Address,
k4^ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
-7J- k N 'RO% 140 3 k 0 W
6.Is(are)the well(s): Vermanent or OTemporary Signa ofCcrtiflOVell Contractor
Date
signing thisforn?,lhereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or &&/o 15A NCAC 02C.0100 or 15A NC,4C 02CO200 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 t owner.
repair under 921 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 I CrW-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:
For multiple wells list all depths if different(example-3@200'and 2@100D-(ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
I Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water
level is above casing,use"+" I
11.Borehole diameter: Bit Off: '3/0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27899-1636
12.Well construction method: :AIR ROTARY
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department-ofthe county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells Producing overJ100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) J Method of test: "A;rAV1*1 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED: (67
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VISITED-BY::'*
Form GW-1 North Carolina Department ofEnvironme
ntal Quality-Division of Water Resources j Revised 6-6-201 S-
i tl -%I n D Alt) Sip C