GW1-2021-08123_Well Construction - GW1_20211109

-1- .
'y.. ._J _,�:•_�i-� -- -=m—.. _ :_ � �---Trier:: .- (� �_m_-.. - -----... .- - -- -- - - -- -- -
Well Contractor Name _ _._..-.—_._- rr Or.l TO I L �r Lis Ti6l l
_ fr. it a GPM'
fL S3v ft : 16p1
NC Well Contractor Certification Number 4'
15.OUTER CASING for multi-cased wells OR LIIVER if applicable)
YADKIN WELL COMPANY,INC. FROM To DWWTL+R THILTOVRSs NATERML
it. ft. in.
CompanyName 16.II INM CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: Ne/ Ie FROM TO DIUVINTER T UCEMESs I MATERUL
List all applicable well construcilonpermits(Le.UIC,County,State,Variance eta) IL ft- 1.118 in.
Stc)i P UL
3.Well Use(checlr mreil L•.sc): ft. ft.
Water Supply Well: 17.SCF3;?r1
Mold TO r?L•_MRRTid� SLOT SIZE TMCIt7fp--SC P9 iLPi=i,
❑Agricultural ❑MunicipaUPublic ft. ft In.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) it. ft. ta.
tMIndustrial/Commercial ❑Residential Water Supply(shared) is.GROUT
01rri ation ❑Wells>100,000GPD MGM To HATEMAL P-MPLACERMNTPUTHOD&Ah.-Iour,T
Non-Water Supply Well: t'' 3 it 1461C POv is
C1Monitoring []Recovery 3 fL It (3vo-Erb J( Pis d 1 j S
Injection Well:
€t
❑Aquifer Recharge ❑Groundwater Remedistion
19.SAND/GRAVE L PACK if o licuble
❑Aquifer Storage and Recovery ❑Salinity Barrier tROnt TO nsATERIAL IvILTHoD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(11'eating/Cooling Return) ❑Other(explain under 421 Remarks) FROM.ft ft.TO DRSCRIPTION color,hardness soillrock typa grxin Eize,ett.
j4.Date Weu(s)Cam plited: 3 a Well ID# O ft- it 6 cap"
-�r
5a.Well Locanou' ;`1' f �
Phone # & f55 3r
f ! ,
Facility/Owner Name Facility M#(if applicable) R' ft.
g
Y W. °dl
' Physical Address,City,and Zip R
21.RMWAPM
County Parcel identification No.(P]N) JCt,I lUl7
5b.Latitude andflongitude in degrees/minutes/seconds or decimal degrees: INFORMATIom PpQrFe
(rf well field,one Wong is sufficient)
22.Certification:
N W " w 913
6,Is(are)the well(,):,6ermanent or ❑Temporary Signaturo bf Cmtifi d Well Contractor Date
By signing thisform,I hereby cent fy that Me well(s)was(were)constructed in accordance with
7.Is this a repair to an eadsting well: ❑Yea or a 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthts is a repair,fill out known well construction information d mplain the nature of the ofthis record has been provided to the well 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 i
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.-,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 620 (ft) Submit this GW-1 within 30 days of well completion the following:
For multiple wells list all depths if different(=mple-3@200'gand 2@100� y con p per �-
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarer level it above coring,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 1,/ (in-) Bit Off: .97 7 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 -
1-2.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie,auger,rotary,cable,direct push,etc.) county environmental health departnrent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
k Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test �d� i-
70%HTH OZ DATE SITE VISITED: �L �i�
13b.Disinfection type: Amount:
VISITED BY:
z i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 i 1