GW1-2021-00030_Well Construction - GW1_20211109

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( � ygri g (; ,t ll�� si�JTi�°I�gi li ,'CIL�1� d' ��-'!l`p For]eternal Use Only:
1.Well�C'optractor infornntion:
J Gp "/ J •a 14.VVATER ZONES
FROM To DESCRIPTION
Well Contractor N me
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for Ii L case ells OR LINER if a Gcable h.
YADKIN WELL COMPANY,INC. FRO�f', _To
nIAML�rER THICIO S 1vIATERIAL
in.it -
Company Name f ,�L (/t 7v - ta'" 3ca 16.ll4NER CASING OR TUBING{ eothermal closed-loop)
2.Well Conswuction Permit#: 3 G•Q _S L T FROM TO DIAhIETER THICIyQVESS 1 GiTERIAL
List all applicable well constriction permits(i.e.WC County,State,variance,etc.)
ft. ft. in. `
3.Well Use(check well use):
17.SCREEN
W er Supply Well: FROM TO DIARIETER SLOT SPLE THICNrtEss RIATERIAL
@'Agricultural ❑Mimicipal/Public ft, ft. in,
Supply) Isylcesidentia]Water Supply(single) g ft• in. i
[]Geothermal(Heating/Cooling PP Y)
Dlndustrial/Commercial ❑Residential Water Supply(shared) IS.GROUT 4^'
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EA4PLACEMENT METHOD 6 AMOUNT
Non-Wafer Supply Well: 0
❑Monitoring ❑Recovery R• ft
injection Welt: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StorirlwaterDrainage ft. it
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG aasch additional sheet ifnecessary)
FROM TO DESCRrPT10N color,hardness,soil1mck type,gmi.size,ctc
DGeothermal(Heating/CooaaRetum) ❑Other(explain under#21 Remarks) ft 7 ft. 5
4.Date Well(s)Completed: �C— r',2 Well nw 7"�b 7 C t o ft. ee � y
51.Well Location: Phone # !* ";�7X 32- 2 ft .•�C7` Qy�rL�] df g ':0
5.14( ft_
J�IN fA C". f n� ft
Facility/Owner Name Fae➢lit ag ft.(if applicable)
/. ft. ft
Physical Address,City ZfP—� ft ft
2LREMARKS
Parcel IdentificationNo.(PIN) O V
County -' 1
5b.Latitude and longitude in degreeshminutes/seconds or decimal degrees: LI`,
(ifwell field,one lat/longis sufficient) 22.Certification:
Zk1,6 S W �l�l vlli�:i Girl I ,
� ` Sipabi f Certifil,d Well Contractor Date
6.Ware)the well(s): Permanent or DTemporary
_✓/ By signing thisfornr,Thereby certifythat the x�elf(.$)was(were)canstructedln accordance with
7.Is this a repair to an existing well: DYes or 15 15ANCAC 02C.0100 or 15A NCAC 02C.0200 We➢!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 ofthisform. 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
(add See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wells
drilled: Cj t 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / g (ft-) Submit this GW-1 within 30 days of well completion per the following:
For muitiple wells list all depths if dierent(az mple-3 aO200'and 2@100�
r 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"+" .*kN
Bit Off: 4J,?(g 24b.For Injection Wells:Copy to W DR,Underground Injection Control(IUC
11.Borehole diameter:• �(in.) 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 .�
(Le,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
a
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100t000 GPD:Copy to DW�CC C A
jj Permit Program,1611 MSC,Raleigh,NC 27699-1611 /l� J °"it�'�11
13a.Yield(gpm) Method of test: C161le � �}�•'i t�
13b.DisinVCftn type:
70%HTH Amount: ; OZ.. DATE SITE VISITED:
VISITED BY: