GW1-2021-04231_Well Construction - GW1_20210415

i
r vn �f 1/G i C, „_
Weil Contractor ldame ws f.
r A ,� ft. 3,2 ft. I ,
ft. c? ft. \
NC Well Contractor Certification Number I&OUTER CASING(for multi-cased yiells)OR LIJ*TER(if applicable)
YADKIN WELL COMPANY,INC. Ar'r� e) 2�21 r i Or.i T� D??l'.TFTlTI T�I i�NasSS r.InTEt?s:�L `
t1 ft. rt. ; in.
Company Name ! , r^CO�a1Cl
P y (� ( f> 3b' , �� tJA r ' 1 , 16.INNER CASING OR T UJ3IP(G(„zo ther�a[closed-loop)
.GC 01 FROM TO DIARIFTER iSZCKNESS RIATERIAL
Z.1�/e!!Construci�on Pes tl,ait#: 0 �
List all applicable well construction permits(i.e.UIC,Counq;State,Pariance,etc.) SO A�-l
17.
r ,fir. '11
❑r c _:rul ti i ❑Lrlipiisrr�?i�I l]IiC I I I-
1 i;-2tia9 Cooling Sa 'oIy �Yrsidene aI Waler Sup;r?y(single)
❑Industrial/COmraerciai ❑Residential \�Iater Supply(shared)
❑IliIgatlOn ❑Wells> 100.000GPD '=:GCI I _o P:L:T=f 7:3e: C_is?3ilrr:hT��ta=.pJa ,Fiitl
--
t•Ie�-ramie: S,,,polysrelh:
❑Monitoring .� ❑Recovery _. s.a L( �' 7 41�
njee:tic rq Well: 5
❑F tluifer I'.charge ❑Groundwater Remediation `, y
1:.J I_/GiILA EL Frl-..l_W applicibl,e)
❑Aquifer Storage and Recovery ❑Salinity Barrier TROrxl TO e1ATE:�AL ERIP3 ACET"JENT nE�TEOD
❑Aquifer Test ❑Stormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/.rock pe,grnin size,etc.)
❑Geotheanal(HeaGng/Cooling?RetGujm) / ❑Other(explain under#21 Remarks) FROM
/
4.IIDate Well(s)Completed: (7 Cg Well I1D# %`�3Ao ft• ft. � � is P'la�G
5a.Well Location: Phone # Li GI— �(ca� C7 i�2 ft. ' .� . t' has •n `
// 371.ft. ft. V ge-i ti
Vs FaciliTy/Owner Name Facility ID#(if applicable) �° ft. �l 1 ft. •t r E /
/ 0` ft. J
�n �l/C�/!P®d!►�/� �� AGt��x v a® /C I(�ed/ ft, ft.
�e
Physical Address,City,and Zip
( 21.RER'IA1ZIfS
W i 162
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification'.
N j
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 04manent or ❑Temporary
By signing this form,I hereby cerlil5,that the well(s)was(were)cwTstntcted in accordance with
7.Is this a repair to an existing well: ❑Yes or CD91 IjA NCAC 02C.0100 or 15A NCAC 02C.0200 A�ell Constuuctian Standards and that a copy
of this record has been provided to the Ii ell owner.
If this is a repair,fill out known well construction hifornration and explain the nature of the
repair under 421 remarks section at-on the back ofthis form. 23.Site diagram or additional well details:
S.For Geoprobe/1DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pagb to provide additional well construction info
construction,only I GVAt-1 is needed. Indicate TOTAL NUMBER of wells - (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: I F 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V 0 (ft-) Submit this GW-1 within 30 days of well completion per the following:
For m:dtiple wells list all depths if d�erent(example-3Q200'and 2Q100')
?.� _�! 24a. For All Wells: Original fonrl to Division of Water Resources (DWR),
10.Static water level below p of casmg: 43_ (ft) Information Processing Unit,1617!MSC,Raleigh,NC 27699 1617
IfTvater level is above casing,rise
(in.) Bit Off: a 't/ 5-
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
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 depaztment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin> over 100,000 GPID:Copy to DWR,CCPCUA
f Permit Program,1611 MSC,Raletgh,!NC 27699-1611
13a.Yield(gpm) Method of testa�' k
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type:. Amount: ['+ t
VISITED BY: 0Le
ova
,�3 �
Form GW- e North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 6-G 20(18