GW1-2021-02331_Well Construction - GW1_20210722

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'Well C'- Naine ontractor FROP.-I TO DESCP"TION
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NC Well Contractor Certification Number LINER 15.OUTER CASING for T!11�sea wells) _fapplicable)
YADKIN WELL COMPANY,INC. FROM To D 'IETER ?Trum KS MATERIAL
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Company Name le&4ito, kyl- 1G.INP(ER CASIlVG OR TUBLVG(keotheEqal c T l gdklo o p)
2.Well Construction Permit#:IWA.P 0(2-0�3 -2041 FROM TO I DIAMETERgS MATIERLAL
List all applicable well construction permits fle.UIC,County,State,Variance,etc) 5klft ft. 6 yq in. SDE-11 PVC
3.Well Use(check well use): ft.
17.SCkRE,2 N
Water Supply Well: MON TO 31-10JETER SLOT SIZE THICIIJIESS HATEPIAL
DAgricultural DMunicipalIPublic ft. ft. in*DGeothenual(14eafing/Cooliug Supply) UKesid.ritial Watte,Supply(single) ft ft. in.
ElIndustrial/Commercial oResidential Water Supply(shared) I&GROUT
DIrrigation DWells>100,000 GPD F III ON I TO PIATEFLIAL ENIPLACEr-MUTT NIETHOD&AMOUNT
Non-Water Supply Well: fr, ft. 14 le PIC 06)fad .3 1/z '64's
DMonitoring DRecovery
3
Injection Well:
DAquifer Recharge oGroundwater Remediation 19.SAIIID/GRAVEL PACK(if applicable)
OAquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL ENIFLACEIV17 NT NE-T HOD
DAquifer Test oStormwater Drainage fi ft.
DExperimental Technology OSubsidence Control ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
rROM TO DESCRIPTION(color,hardness,soil/rock type�grRin size,ern
[]Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 4 0 ft. 5
.)30 -0
4.Date Wells)Completed: Well lD# A-Aj-rv%-P- 66 fit. ft. 1-e
Sa.Well Location: Phone #J3C- 2.S-2�-COW
Facility/Cfwner Name Facility]D#(if applicable) ft.
La^6q ,Fc?im1SA YhJk(k*1VJ1,L
Physical Address,City,and ZiV d
ect 21.REMARKSRKS
V\
C e",
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
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*e Cztffi
6.Is(are)the well(s): aermanent or ❑OTemporary Sigaa of ed 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: 0Yes or 8No 15A NCAC 02C.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.) 4
-(ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths if different(ezample-3@200'and 2@1 OOD
4qo (ft) 24a. For All Wells: Original fohn to Division of Water Resources (DWR),
10.static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: &OLO 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UQ
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-163 6
AIR ROTARY
12.Well construction method: 24c.For Water Supply and OperilLoop 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
13a.Yield(gp-) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH Amount: Oz DATE SITE VISITED: J01 -
13b.Disinfection type: 1 1
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources,' Revj1g4L"-20l8
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P RICE MRW01