GW1-2021-02328_Well Construction - GW1_20210722

WellConh-aetorName r'r-'+•! eO D2SCri0riiC.iI I
ft. �I 1 ft. Jq G P,i" j
ayS'a� _
NC Well Contractor Certification Number f t I$o It SG G P�'-1 1
15.OUTER CASING for multi-rased wells OR LEhIER if_applicable)
YADKIN WELL COMPANY,INC. FROM To DL EETER4 THICLCNE55 MATERIAL
ft. ft. k 'in. I
Company Name (eta.V tr V(9 'v 1
`� Y 6 0`3 2°� r 16.HINE t CASING OR rUBING eothermal dosed-loon)
2.Well Construction Permit#: P R W L 2�2( oO 6 �fQ rRona To DL410-TER I TH7CfMSS 1vrATsRML r /�
List all applicable well construction permits(1e.UIC,County,State,Va iance,etc.) t ''K ft. G Yy in.
3.Well Use(check well rise): ft. ft in.
Water Supply Well: li.SCRIEZ N
MOW TO DUU.I?TER SL OT5t2e TE-31C1t1•1E50 i:lATiP.i._i
❑Agricultural ❑,M�/unicipal/Public ft. ft. C/❑Geothermal(Heating/Cooling Supply) d esidential Water Supply(single)
❑Industrial/Commerciai ❑Residential Water Supply(shared) ld 6RG15 T
ohrigation ❑Wells>100,000 GPD reom TO W_TEL1AL EMPLACUMNT Mr•THOD G AJ:IOUNT
Non-Water Supply Well: C) fi. L ft. 14a Ie Pl t] vfref (r 6
❑Monitoring ❑Recovery �i ft• '9 ft ©vtcr GroJA I v Ct $ b4 5
Infectiou Well: 55
ft ft. ij
❑Aquifer Recharge ❑Groundwater Remedisiion '
❑Aquifer Storage and Recovery ❑Salinity Barrier I9.SAND/GR AICE L PACK(if applicable)FRor.•I TO NAIV L, ENPLACMIENT NOTHOD �(—
❑Aquifer Test ❑Stormwater Drainage_ ft. ft.
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer � - 20.DRILLING LOG attach additional sheets if nerrssa
❑Geothermal(Efeating/Cooling Return) ❑Other'(explain under#21 R arks) FROM TO DESCRIPTION color,Lnrdarss,soiUrodt rain sa etc
PP ��, ft ft. Sot li
4.Date*04('s):Completed: G 1 WellE10 9 "R• GS fL 5*Adr0Cit 3
SR.We u Loeatibn Phone #3t -3 'S" ®1 7 �'`s\ \' o� ft 6r4 1�
ft:.�
Facility/Owner Name `LFacility ID#(if applicable) ft F
ZI
ft.m P_4-�LA &i A1
Physica/lAddress,City,aid Zip ft. ft J U L la
21'RWARKC inn Q0
County ; Parcel Identification No.(Pit")
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: v
3� Zq, [kJ- N 90- 32., a W !. f
- 6.Is(are)the e well(s): 4ermanent or ❑Temporary Si of abrdfied Well Contractor Date ,
/ Bysigning this form,I hereby certify that the wells)was(were)constructed in ac'�irdance with
7.Is this a repair to an existing well: Dyes or Mo 15ANCAC 01C.0100 or 15ANCAC 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 thisform.
_ 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 i GW is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: 24.SUBMl'TTAL 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 if diffawd(example-3Q200'and 2Q100) y p p g:
use
24a. For All Wells: Original form to Division of Water Resources (DWR), -
10.Static water level below top of casing:
If water level ix above casing, �� (ft.) Formation Processing Unit 1617 MSC,Raleigh,NC 27699-1617;
"+"
t Bit Off: �s g� 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
Cie.auger,rotary,cable,direct push,etc.) county environmental health department.of the'county where in
� i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells vroducino over 1100,060 GPD:Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Go Method of test: fi//��t'Ir I
70%HTH Oz DATE SITE VISITED: .g „
13b.Disinfection type: Amount:
h I
VISITED BY:
I � +
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResonmes Revised 6-6-2018
7 �n r i r • _ I t ' n�� _1: