GW1-2021-02343_Well Construction - GW1_20210722

4 i
We1lContractorName i•i.Ci.l TO j DZSCI, MOU 0ft. 140 tt. 604PPA
46D rat ft. ft. n
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased:wells OR LWER if a plicab1 ?��
YADKIN WELL COMPANY,INC. FRon2 To DIAR�ICR THIC[INCss 4R1AL
33� G 4 in.
• Company Name tJ O s O.�' I
(qd K!, 16.INNER CASING OR TUBING thermal dosed-loon)
2.Well Construction Permit#: i/S FA f- '01 2C3`7 �021 FROM To DIPMTER I THmiamss I MAMRLIL _
List all applicable well construction permits(r.e.UIC,County,State, Variance,etc.) ! I ft. -7� fr. (/y m. 5 O�a P V c
3.Well Use(cheep well use): ft. 1 ft in.
Water Supply Well: 17.SCRE2i I
FRON TO DIAPdET'eR I SLOTSTME I TOC;a•rc.SS IP.7rrini:•1.
❑Agricultural ? ❑Municipa"ublic it, ft.
❑Geothermal(Heating/Cooliug Supply) 1y53�esidential Water Supply(single) ft. ft.
01ndustrial/Commercial ❑Residential Water Supply(shared) Iq.GS.UUe
❑Irrigation ❑Wells>100,000 GPD MON To PLATERIAL eMPr.ACEr-MNT P.OTROD c A110UNT
Non-Water Supply Well: Q tt. 3 ft. Hole feel ba
❑Monitoring ORecovery
Injection Well: 3 �3 ft Cxodl 31�L 4S3
❑Aquifer Recharge []Groundwater Remediation
19.SANDIG-RA�E,L PACK of applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier i nor.1 TO 1YL1Tr,RLtL EP.IPLACt�.P.•T VT n•IF:HOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
DGeothermal(14eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain sae,etc.
Q ft. V
4.Date Wells Completed: y I Well ID# _4- fr fr r
Sa.Well
hone # 33�1/3 9g/l .
ell Location:
Facility/
O
wner Name Facility ID*'(if applicable) fL fL 1 31
ft ft. ,
Physical Address,City,"d Zip R fL
C -
� - j n 21•REMARKS e
� 4 1iYJ
County Parcel Id e fication No.(PIN) atC , r or j�Cr
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weU field,one lat/long is sufficient) 22.Certification;<
6.Is(are)the well(s): Ndermanent or ❑Temporary Si of Cbrtified Well Contractor: Date
J By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1Vo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandardr and that o 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 ofthisform. 23.Site diagram or additional well details`
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe 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 ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. -
drilled: I 24.SUBMTITAL INSTF.UCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all'depths if diferent(example-3Qa 200'and 2(a)100� Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: t/0 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarer level it above casing,use"+^ Information Processing Unit 1617 WC,Raleigh,NC 27699-1617
11.Borehole diametei: (in.) Bit Off: l 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
(i.e,auger,rotary,cable direct push etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: /� 24d.For Water Welts producing!over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm)r t/O Method of test. A 1 C Permit Program,1611 MSC,Raleigh,)NC 27699-1611
70%HTH pZ DATE SITE VISITED:
13b.Disinfection type: Amount: 1
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2019