GW1-2021-02346_Well Construction - GW1_20210722

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FROP1.1 To DESCM-TION Well Contractor Name
_?S�100 JUL ft. ft.
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NC Well Contractor Certification Number 0sessing U t15.OUTER C-ASPIG(for multi-cased wells)
'e P'i*I DUMETER L (if 2PI
YADKIN WELL COMPANY,INC. DWIR�ecjion PTRIM-INI T111L
ft. in. I
Company Name 16.INNER CASING OR G(geo thermal closed-loop)
2.Well Construction Permit#: 7 FROM TO DVJVM,TER TEUCKNESS MATERLAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft.
ft- in. S I I 4 O& P VC
3.Well Use(check well use): ft. ft, in.
l
W 17.SCRE 2 later Supply Well: M-1101"I TO DIAPJETPR! SLOTME THICIGIESS HATPRLAL
DAgricultural OMunicipaUPublic
DGeothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ft. It. in,
01ndustrial/Commercial OResidential Water Supply(shared) �f&GROUT
DIrrigation DWells>100,000 GPD FrO1111 TO NIATERIAL UUPLACUBEHT ATER TROD iNNIOUNT
. CIA liq J 10'e V merit
Supply Well: ft
to -4-rift at/1 "IT
oMonitoring ORecovery fr. 21 ft. JR-m
Injection Well: ­tdtt-)! fqAf
0Aquifer Recharge 00roundwater Remediation
19.SAND/GRAVEL PACK-(iltapplicz1ble)
DAquifer Storage and Recovery OSalinity Barrier FROM TO ImTrRiAc ED, LACEE IVIENTIA-M,TUOD
DAquifer Test OStormwater Drainage ft• f t.
DExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets it necessary)
DGeothermal(Ileating/CoolingRetum) - 0 Other(explain under 421 Remarks) FROM TO DrSCR&TfON(color,hardness,soillrodc type rain size,etc)
ft. ,/
5'Q f
4.Date Well(s)Completed: 6-14-9 1 Well lD# 0 110 ft-140 It. <1041
"
5a.Well Location: Phone ft. 'e A6
S ea 'n &T t A!,I ft.
Facility/Owner Name Facility IID#(if applicable)
ft. ft.
Physical Address,City,and Zip fL fL
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees
(if well field,one lattlong is sufficient) 22.Certification:
0 Q N W ILI
IMAAL�
6.Is(are)the well(s): ermanent or OTemporitry Sigua.t'Oe of Certified Well Contractor Date
By signing thisform,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ANO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Imown well construction information and explain the nature of the ofthLy record has been provided to the well owner.
repair under 921 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: It 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ?63�
For multiple wells list all depths if different(example-3@200'and 2@100') "-(ft Submit this GW-1 within 30 days of well completion per the following:
rio" 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
M4 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: 5 24b.For Injection Wells:Copy to IDWR,Underground Injection Control (TUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27609-1638
I i
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 ver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Tt Method of test; Permit Program,1611 MSC,Raleigh,NC 27699-1611 70%HTH Oz DATE SITE VISITED: .2
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division o6vater Resources Revised 6-6-2018
P R I c E
4001111166wi;