GW1-2021-02324_Well Construction - GW1_20210722

Well Contractor Name rr:OLl TO iF�C.0 rioil
NC Well Contractor Certification Number V r
M OUTER CASDYG far multi-casedells w OR LDVER if a licstble
YADKIN WELL COMPANY,INC. FROM To DIAIt1TrR1,TmamisS TrRf/1L
ft. ft. in.
Company Name
16.DINER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: `� FROM To I DIPLIKETER I MUCKNrSS MATFUTAL
List all applicable well construction permits(i e.IIIC,County,State,Ymiance,eta) ft /01 ft. in. 88
3.Well Use(check well use): fi' D' in.
Water Supply Well: V.SCeU.21`I
e e Ord TO DIALNETER SLOT SIME TarC_GIESS P.iATEPi
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Kesidential Water Supply(single) it. ft.
❑lndustriaUCommercial ❑Residential Water Supply(shared) lam.GFGUT
❑Irrigation ❑Wells>100,000 GPD reord I TO MtA MMIL EMPLACETtIENT PMETaOD 6-AMOUNT
Non-Water Supply Well: it. Kok fductuJ Q S Imp.3
❑Monitoring ❑Recovery s �O C.k PV d 3 K.s
Injection Well: It
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAM/GRAVEL PA.CX(it applicable) `p»,
❑Aquifer Storage and Recovery ❑Salinity Barrier iTtOM TO MATrRIAL EM UEP-P-M.9T NM—AROD<
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRM.LING LOG(attach additional sheets if necessary)
❑Geothermal(Aeating/Cooling Return) ❑Other(explain under#21 Remarlm) FROM I TO D2SCRIPTION color,hwtness,said—k type,V%in Are,etc
4.Date Well(s)Completed: Well w# �'S�� 7 7 ft. .7�i� �R el I-Ir
ft fL
Sa.Well Location: Phone # 104t
Fecr7ity/Owner Name Facility M#(if applicable) ft
1 �S P lad lvGrl-%'�� ft Physical
Address,City and 71p
:NC/ 21.RTtMARKC t..fa �eSIII
r �6�IUllr" � c;�-t;011
County Parcel No.(Flit) . ;-
;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwan field,one WonIlis sufficient) 22.Certification:
6.Is(are)the well(s): Permanent or ❑Temporary Si of efied Well Contractor Date
Bystningthisform,I hereby certify that the welt(r)war(were)constructed in accordance with
7.Is this a repair to an eristing well: pYes or o 15A NCAC 02C.0100 or ISA NCAC OaC.0200 Well Construction Standards and that a copy,
Ifthis is a repair,fdl out known we construction bzrormation Yde=xplaln the nature of the of this record has been provided to the well owner.
repair render#21 remarks section or on the bock of thisfa m.
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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Crver'in Remarks Box).You may also attach additional pages if necessary.
dolled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells IW all depths if&fferent(example-3@200'and 2@100� Submit this GW-1 within 30 days'.dwell completion per the following:
10.Static water level below top of casing: SO ( ) 24a. For All Wells: Original for to Division of Water Resources (DWR),
If water level is above casing,use"+^ Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: s 00 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 deparhnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produrinti ver 100!000 GPD:Copy to DWR,CCPCUA
( Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5-0 Method of test: ��� F ; I
70%HTH OZ DATE SITE VISITED: ' 2
13b.Disinfection type: Amount:
VISITED BY: !/
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