GW1-2021-02326_Well Construction - GW1_20210722

Well Conhaetor Name FIIO%1 TO rr1°C: Tar it
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LAVER if a lieable
YADKIN WELL COMPANY,INC. FROM TO DLUMER ;TSICItNEss TERIAL C
Company Name Q
16.1NNl�t CASING OR TUBING(geothermal dosed-loon)
2.Well Construction Permit 4: W L •Z o D if_qO FROM TO DIAMLTL+R TffiC DMS MAMMUL
List all applicable well construdlonperndts(LE WC,County,State,YaNance,eta) 4 ft 9 ft. e.�/y in. 51,E 11 evc- �
3.Well Use(chectr well rse): ft. ft. % in.
Water Supply Well: 17.SCP E2i`I
eT.Otd TO DIAMETe':i SLOT SIZE TUIL94=S0 r.i-T'ErUL
❑Agricultural ❑MunicipaLTublic ft, ft in•
❑Geothermal(Heating/Cooling Supply) Paesidential Water Supply(single)
01ndustrial/Coninim-vial ❑Residential Water Supply(shared) (�
!g GSUU e I
❑Irrigation ❑Wells>100,000 GPD Idol TO MATERIAL EMPLACEN—MNT MrTHOD r.aJ•J0UNT
Non-water Supply Well: tl S fr 1401c Pw
❑Monitoring' ❑Recovery 5 ft 3-3 ft vwX Ga,t PU d L1 ba S
Injection Well: ft ft
❑AquiferRecharge ❑Groundwater Remcdiation19.SAND/GPA1'RL PACK(H applicable) r
❑Aquifer Storage and Recovery ❑Salinity Barrier r-RoM TO MATERIAL EMPLPCsTs�Ni ern zaon
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology + ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,bardness,saalrock a sin,ett.
❑Geothermal(tieating/CoolingRetum) ❑Other(explain underj121 Remanlss) 0 ft O ft. rt
4.Date Well(s)Completed:G !7 e11 well ID# S�o O ft' SD7 ft6en-Ar
�n ft ft v
5a.Well Location: Phone # /D
,�cts,r e-s �iJ 4 c, J ZAIC p ft ft 1 �. 1
FacWty/�Ovmcr xama Facility M#(if 1icable) ft ft : Elm
e /Y A+4 e Q1 5/ ^PV6 44 J< it ft. c�.. 21•'
Physical Address,City,and Zip ft ft
ZL RK ARKS al t r�u; a
County Parcel Identification No.VIN) '
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
gfwell field,one laillong is sufficient) d 22.Certification: of
3C 5Lt Y®(p'N D 6 30,C3-C W
G . I
—Z a b%& /
(A9 `i
6.Is(are)the well(s):.4 ermanent or ❑Temporary Si of C ed ell Contractor Daie
BysigningtUrform,I hereby certify that the well(s)was(were)constructed in accordance with•
7.Is this a repair to an erdsting well: ❑Yes or kqo 1SANCAC 02C.0100 or ISA 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 beenprovided to the well owner.
repair under#21 remarky section or on the barkofthisforn.
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 Remarlrs Box).You may also attach additional pages if necessary:_
drilled: 24.SUBMITTAL INSTRUCTIONS f.
9.Total well depth below land surface: SIN (ft) Submit this Gw-1 within 30 days',of well completion per the following:
For multyple wells list all depths if d fff a at(example-3@200*and 1Qa 100D
10.Static water Level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR);
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level it above casing,use"+"
Bit Off: S.4J ? 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�•) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY 1
12.Well construction method: 24e.For Water Supply and Open-Ldop Geothermal Retarn Wells:Copy to the
(Lt.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Weals producing over 100.000 GPD:Co to D
l Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA;;
13a.Yield(gpm) Method,of test: 4o r j e
a DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: 02 f OZ
VISITED BY.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Re 6 2018 -