GW1-2021-00282_Well Construction - GW1_20211213

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We Contractor Name t-,rlft. 5-�� � M
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NC Well Contractor Certification Number 15.OUTER CASING for multi-rased wells OR LINER R a livable
YADKIN WELL COMPANY,INC. PRon �f_ TO
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Company Name � j`�,J a',�..�,j/- 7� 3 �:i� 16.INNER CASING OR TUEING thermal closed-moo
2.Well Construction Permit#: ME( FROM TO DLAMrTER I THICKOMSS KAT RiAL
List all applicable well construction permits rLe-WC,County,State, Variance,e1e) R 19 f ­, 'n• a L
3.Well Use(check well use): ft. ft in.
l7.SCP`2i l
VVaterSupply�4re11: F•r_or.-i TO D&•.NETZ.t SLOTSIZE TMC:Cr_ESc 1.3_'.WH1_L
❑Agricultural ❑� LLMunicipal/Public ft. ft. in..
❑Geothermal(Heating/Cooling Supply) SResidential Water Supply(single)
❑Industrial/Conmiercial ❑Residential Water Supply(shared) 13.GROUT
❑Irrigation ❑Wells>100,000GPD I-n0&1 TO P.tATER1A_ EMPLACEr.ENTHEISODrAHOUNT
Non-Water Supply Well: o l'' ` fr' ion.. JI qp o u rw
❑Monitoring ❑Recovery ft , s ft. ow I
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Injection Well:
fr.
!ale Owl
❑Aquifer Recharge ❑Groundwater Remediation fr. I I v
19.S.AIID/GRA1TL PACk-(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FpOrd TO MATERIAL I ,:rfPU_M.�;TKE HO
❑Aquifer Test OStormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control. R R
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attacb additional sheets if necessary)
❑Geothermal(1leating/Cooling Return) ❑Other(explain under#21 Remarks) ao-Al To ' R so.-Z
DZrSCRiPTION colon hardness,aoillmek 'rain c etc
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4.Date Wells)Completed:��-�'`.� Well [I/s ' ft,Oft' o 30WT e,4 J&W rey v t-4o
5a.Well Location: Phone #'Q V- k2.3 z., ft. ft`133
R fr.
(Ajen 6 Pn dry c 4t1'
Facility�ame Facility ID#(if applicable) ft. ft.
f Fop-er f e've r[n. R ff.
Physical Address,City,and Zip ft. &
Mikak Q� 21.REMARKS a
(JtJ O S -/G-I 13row-k at- O J.
County Parcel ldmtification'Igo.MN) /
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1/ O 1 94D L-4' +�`t b ��• h e w" �' w
(if well field,one lat/long is sufficient) 22.Certification: C<
3 r g• 1`?q N �� ` b�. 1� W
6.Is(are)the well(s): OPermanent or ❑Temporary Sigp6e of Cezlifid Well Contractor Date
Bysigning this form,1 hereby certify that the well(s)was(Srere)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 1114o I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarla 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
driIied: 1 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 list all depths ifdifferent(example-3@70 'and 2(a)100� y p p g'
/ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: APO (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If-water level is above coxing,use"+"
11.Borehole diameter:
1/ (in.) Bit Off: �.�7 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC) J
Prograrr 1636 MSC,Raleigh,NC 27699-1636 t
AIR ROTARY �l
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 GPD: Copy to DWR CCPCUA
S' L
13a.Yield(gpm) Method of test: -�"90 JW.J
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: 1r -7 OZ DATE SITE VISITED:
7- 2, e2 haf/'r,Mrk
VISITED BY: .
Form rrur'- utment of Environmental Quality-Division of Water Resources Revised 6-6-2018