GW1-2021-00189_Well Construction - GW1_20211213

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Well Contractor Name
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if applicable)
YADKIN WELL COMPANY,INC. FROM T DLUIrTER I =1CrINESS JMATERJAL
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Com Name � C�
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2.Well Construction Permit#: t FROM TO DIAMETER THICKNESS MATE,RIAL
List all applicable well construction permits(Le-UIC,County,State,Variance,etc) I ft. qq ft. & r/ in. sjg- �(� v C
3.Well Use(cFectc Weil ese): ft• ft in. ,-A
Water Supply Well: 17.3CP,r i I - —
r'r:Of:i FO DIAMETei SLOTSiZL TeTst4tESS C'1-TiEi_s ^
❑Agricultural ❑Municipal/Public ft. ft. `D
❑Geothermal(Heating/Cooling Supply) Ivesidential Water Su e)
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01ndustrial/Commercial ❑Residential Water Supply(shared) 11.GROUT
❑Irrigation ❑Wells>100,000 GPD MOM TO AvTERIAT_ EMPLACE,r.ZENT c•MTSeD&APIGUNT
Non-Water Supply Well: O f i. 3 fr•
❑Monitoring ❑Recovery 3 f, It L
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Infection Well: Lft. ft.
❑Aquifer Recharge ❑GroundwattsrRerediation 19.5A51D/Ge'AlrisLPACI�(iiapr�icnblel
❑Aquifer Storage and Recovery ❑Salinity Barrier iRoM TO MATZRIAL LT PLnCMr:1_ar;r, 3OD
❑Aquifer Test ❑Stormwater Drainage fr
❑Experimental Technology ❑Subsidence Control ft
[]Geothermal(Closed Loop) ❑Tracer 2f.DRILLING LOG(attach additional sheets if oerrssaT)
❑Geothermal(1-Teating/Cooling Retain) ❑Other(explain under 421 Remarks) FROIti TO DESCRIPTIONcolor,hardness,soiVrock in sae,eta
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4.Date Well Completed: ,r' 'A I Well W# ft ft � '
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5a.Well Location: Phone #(�('s.>06 —3 7 rd 3 7 ' 3 Y Z I r 6
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Facd];ity/OwnE Name Facility ID#(if applicable) fr' ft•
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Physical Address,City,and Zip ft ft
6-4v I_ki 21.RRMARKS
County `tom Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Clfwell field,one latnong is sufficient) 22.Certification:
`( ? e/ N 6aJ ° 3` 1)" W _
6.Is(are)the well(s): i4ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,thereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing Well: Dyes or PlNo 15A NCAC 02C.0100 or 154 NC4C 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and eaplain the nature of the of this record has been provided fo the well owner.
repair under#21 remarla section or on the back of this form.
23.5ih diagram or additional well details: t
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 v
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells lint all depths ifdii ferem(erample-3@200'and 2(a)100�
eC) 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
lfwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: FG �) f f 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPI►: Copy to DWR,CCPCUA
13a.Yield(gpm) T Method of test: .^i
t a�/' Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 70%HTH Amount: t?© OZ DATE SITE VISITED:_� Z,Q
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A?6 VISITED BY:
r--^ nent of Environmental Quality-Division of Water Resources Revised 6-6-201 B