GW1-2021-02349_Well Construction - GW1_20210722

11.---:r✓�_— --_.1 ,..-.- C -t v 1 F i':iaif Ust
_ ` ~
r Cr1 eo ux°Cr.F.T1Git
JUL ;' 2021 3 ft 33 E r
ft.
NC Well Contractor Certification Number r.i , l i s• 15.OUTER CASING for multi cssed;wetls dR[LIhiER If a !usable
�f ,t-n ,• ,r:f7 fit
YADKIN WELL COMPANY,INC. ;.,`',•.�t i3Oi1 4 sons To I D>AMEM Mucrawss Tattiaa,
ft.
Company Name a
16.110=CASING OR-TUSING therms!rlosed-loonl-
2.Well Construction Permit#: dv, I FROM TO DrA14=R, TMENNESS" MATERIAL
List all applicable well construction permits rK e.UIC,County,State,Patiance,etc)
3.Well Use(check well use): . in
Water Sapp3y Well:
Z•ord To DIANI-EnR £LOTSIiE TS1Gr4iF�^S. HATEMAL
❑Agricultural DMunicipal/Publio ) ft rn
❑Geothermal(Heating/Cooling Supply) Aeiiidential Water Supply(single)
b1ndustriat(Commercial DResidential Water Supply(shared) ie.`Gr.UUi
❑Irrigation l7Wells>100,000 GPD Feoni T® rt+TE1�r;+t` :EMr'LACEhiENT-AM OD Ca Als OWT-
Iron-Water Supply Well: ® {i CZ•
❑Monitoring ❑Recovery eft a tit; �J
Injection Well: ti. .
❑Aquifer Recharge ❑Groundwater Remediation
19.9APIS}/GRAIM-L 1'_Clf(H a icible
❑Aquifer Storage and Recovery ❑Salinity Barrier reona To MAiER➢Ar [2'A"APLAE1Tf MEMOD. "
❑Aquifer Test ❑Stop wwater Drainage ft ft.
t
❑Experimental Technology ❑Subsidence Control 'ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLUgG LOG athch additional sbeets i(neeessa
❑Geothermal%eating/Cooling Retum) DOther(explain under#21 Remarks) moons To• r aFs(lamriox color bar sa ,ocalmetc • o at
4.Date Well(s)Completed: "L�•�f Well ID# 0p
5a.Well Location: P�Jhon
ft. ft
Facility/Owner Name �— Facility M#(if app usable)
6 x Clr e.s O V e V/.gp/
f
Physical Address,AACity.and Zip
21.RRMARTIR -
04
county 6-cel Identification No.(PIN)
Q:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ` 22.Certification: /1
d
6.Is(are)the well(s): ermanent or ❑Temporary S;ipWm ofed Well Contractor Daft Og
Bys4ningthisform,!hereby cenV► that the well( was(werr)eoni*ueted to accordmiee with
7.Is this a repair to an existing well: ❑Yes or o IJU NCAC 01C OD of ISANCAC 01C OZ00 WeU ConsiruEdon S4aedah&and that's copy
If this it a repair,fill out larown well construction fnjormation and explain the nature of the ofthis re/s�thc
een provided to the well owner
repair under#21 remmkrsection or on the back ofthisform. 23:Site or additional Well details s'
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You back of this pagetoprovide additional well constructioninfo .construction,only 1 GW--1 is needed. Indicate TOTAL NUMBER ofwells (add'S Remarks Box).You may also attach additional pages 1f necessary.'
drilled: >, 24. BhIIZTAL IN3mucnONS G
9.Total weII depth below land surface: `��3 D A) }
Submit
For multiple wells list all depths ijd ffawd(example-3@20 'and2@700) this,G�i'-1 witlun30 days of tYell completion per the following
10.Static water level below top of casing: • (ft.) Via- For All Wells: 0liginal Enna to Division•of Water Resources (DWR),`.
Ijwater level it above casing,use Information Professing Unit.161'1 MSC,Raleigh,NC 27699 16I7
11.Borehole diameter m. Bit Off: 24b.For Infection'Wells:Copy I L , &Underground Injection Control(IUC)
——6�—( ) Program,1636 MSC,Raleigh,NC27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Sap Dly and rl Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary,cable,direct push,etc.) county ammmnental health department of the comity where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells i)—dudne over 100.000 GPD:Co D Copy to WR,CCPCUA
1 Permit Program,1611 MSC,Rslei NC 27699-1611
13a.Yield(gpm) Method of test ? I "
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: t
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised"-2018