GW1-2021-00354_Well Construction - GW1_20211213

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1 _ _ Woa�!^S D CF
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Well Contractor Nam e
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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 TO DIMtET,R TEncla SSS MATERIP_L
ft. ft. in.
Company Name '( C ri- 71"3O 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 0-7 Y Z FROM TO DLllME-TER I TMCICNrSs I MATERIAL
List all applicable well constr action pa-mits(>_e.UIC,County,State,Variance,etc.) /_C ft. 1 1 ft. G Ile in- S Fa I
3.Well Use(check wet;use): `r ft• ft. in.
17.SCREEN
Water Supply Well: T R Or•I TO DI.:P.-IETER SLOT--I=r_ THTICIO'IESS N,1.7EP.1LAL �
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) *esidendal Water Supply(single) it. ft. pn,
v
❑Industrial/Commercial ❑Residential Water Supply(shared) 1g.GROUT
❑Irri ation ❑Wells>100,000 GPD PROA1 TO MATERIAL Ec•IPLACEC>:'nTr�1=T&GD c _t:IOmIT
Non-Water Supply Well: ir. ft. of P' PojW IC.`
❑Monitoring ❑Recovery ft. ft. GftNTt 4
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
'r► 19.SAND/GRAVEL Pr1Cit;(if applicable)
[]Aquifer Storage and Recovery ❑Salinity Banier FROM TO IMATEPIAL EAlPLe±CEhIENT ltrre_. E 0 D
❑Aquifer Test ❑Stotmwater Drainage fL ft'
Vv
❑Expenmental Technology ❑Subsidence Control ft. fL
,
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) �✓
FROM TO DESCRIPTION color,hardness,soil/rocke, in sae,etc fi J
❑Geothennal(fTeating/Cooling Return) ❑Other(explain under#21 Remarks) d ft. 7 d ft. d )
4.Date Well(s)Completed: I3 Well ID# ^6 3 Z ft ft.
q
5a.Well Location: Phone # ft. ft.
I l���b 3 B
ft. ft.
j Facility/Owner/Name ,[ �Facility ID#(ifaappplicaabble)
f `7axe
Physical Address,City,and Zip ft. & PEG 3 ,
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Y (ifwell field,one lat/long is sufficient) 22.Certification:
3� l�� 1;OFK N �I t!�• VF36 W4� II 3
6.Is(are)the well(s):APermanent or ❑Temporary Signature f Certifitd Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yea or *0 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well 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 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.
drilled: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L4� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths iit different(example-3 r®200'and 2®100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is above casing,use"+"
11.Borehole diameter: (in.) Bit Off: St L?qG 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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 department of the county where installed `\
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
` Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: I'f t�d �O >
o (G
13b.Disinfection type: 70/o HTH Amount: OZ DATE SITE VISITED:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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