GW1-2021-02323_Well Construction - GW1_20210722

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Well Contractor N e FLON TO C rTi?i!
NC Well Contactor Certification Number 15.OUTER CASING for multi-ca a wells OR LIIVER if a plieable
YADKIN WELL COMPANY,INC. FROM To DIADusTela rlDcravLssXATMAL n
Company Name ft. in,
ft. I
��` ,� ��®� 16.EgNER CASING OR TUBING(l ottrermal closed-lot
2.Well Construction Permit#: t FROM To DLUKnTER I ,TffiCfams I lvtAxaaiat
List all applicable well construction penults(ie.WC,County,State,Patiance,eta ! IL
ft /LS y in• ' H�
3.Well Use(check;vell use): ft• ft j i,in.
Water Supply Well: 17.SCU,2i l
MPOW TO DIAMETER SLOTSIZE I THmmai=S5 I r:9=iuL-1AL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) 031C/esidential Water Supply(single) ft. ft. in. '4
01ndustrial/Commercial ❑Residential Water Supply(shared) l8.GROUT
DIrrigation ❑Wells>100,000 GPD MON TO rt1 TLTRIA� EMPLACE rENT I:T'FHOD r AMOUNT
Non-Water Supply Well: tt•• r ft
❑Monitoring ❑Recmwery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation €t ft.
19.8AM/GFsAITL PACE:(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bonier r 011.1 TO DIATrRIAL 10 PLA_CeEMT N1LenoD
❑Aquifer Test ❑StorarwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additiodal sheets if oeressa
❑Geothermal(FI'eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DBSCRIP17ON inter,hardness,soil/rack type in sbre,eta
d ft 5- It.
4.Date Well(s)Completed: "��-� Well ID#7`t!`1r/'e .S S ft 0
Sa.Well Location: t Phone #31JC,.-40%-2S-71 ® rt J 4k f fL dais c)
. G sa'
-�- g ki A ft ft.
J
Facility/Owner Name Facility ID#(if applicable) ft. M
"? AA aA rQ Q�a 7
Physical Address,City.acid Zip ft. fL
S"u 21.REh AR33 JUL
County Pared Identification No.(FIN) r,cRi i. l)iZ1I
Ir1^v(li 1„lr4 i:011
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) (� 22.Certification:
Ito
6,Is(are)the well(s): 4er.anent or ❑Temporary Si of Cqffed Well Contractor Dates
_� bysigning thlsform,I herby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �Vo 15ANCAC 02C.0100 or ISA NCAC 02C.0200 FRI/Construction Standards and that a copy
Ifthis is a repair,fill out Imown well construction information and explain the nature of the of this retard has been provided to the well owner.
repair under 921 remari r section or on the bark 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 OW is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer �, (ft
For multiple wells lest all depths if dr�erest(example-3(a)20 an 2@100) ) Submit this GW-1 within 30 days of well completion per the following:
10.Sffitic water level below tap of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
Ifwater level is above casing,use"+^ Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC AIR ROTARY �27699-1636
12.Well construction method: 24c.For Water Supply and Open-L'oop Geothermal Return Wells:Copy to the
(i.e.anger,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
f" Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test:
13b.Disinfection type: 70%HTH Amount..:. vo►:!•7 OZ DATE SITE VISITED: G'-�µ•,!i( 2�",
VISITED BY: p.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 4 " Revised 6-6-201 a