GW1-2021-02391_Well Construction - GW1_20210722

7
i L f,2&i f2
Well Contractor Name FROM TO I DEXPEP,770il _i
1 1 1 q0I_q0Z
30 3 424 1-_ Itio
4C Well Contractor Certification Number Lto I,. GLI
15.OUTER CASING(for multi-cased W211s LAYER if applicable
YADKIN WELL COMPANY,INC. FROM TO I DIA-HE TER, �THSS
Company Name I I
16.INNER CA SING OR T ING(g6othermalclosed-loop)
2.Well Construction Permit#: AVA FROM TO DIAMra%. THICHNES MATERIAL
4 I r)
List all applicable well construction permits(i. UIC,County,State,Tlarlance,etc) t. n- GC
3.Well Use(check weld use): ft. fr. in. d6,L, sAd
Water Supply Well:
r-RON I TO DI-METER SLOT SIDE THIC104ESS i'rIATEPJAL—.
Agricultural G f ON4unicipaUPublic ft. ft.
DGeotherinal(Heating/Cooliug Supply) oResidential Water Supply(single)
DIndustrial/Conimercial DResidential Water Supply(shared) 48.GROUT
DIrrigation OWells>100,000 GPD PROM TO il.,_'�TERVUL EPIPLACEU 14T N-TETHOD L,AJdOUNT
Non-Water Supply Well: D ft. 3 . It.
DMonitoring ORecovery 3 fr. 20 ft- �4
injection Well: fr
DAquifer Recharge OGroundwater Remediation 19.8,41IDLIGERLAICu L PACK(if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROM To ARTERIAL EIT11 LACEH-ENTMEIROD
DAquifer Test oStormwater Drainage
DExperimental Technology DSubsidence Control fr. ft
DGeothermal(Closed Loop) []Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soittrack type,grain size,etc.)
DGeothermal(Ileating/Cooling Return) DOther(explain under#21 Remarks) D ft. ft.
7 Tip I
4.Date Well(s)Completed:T- Well ID# t414 0 /O ft!y A&
5a.Well Location: Phone # 5.34-7.)7- 2y Loll UA I kl 6,4,,�e
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6 V ft. C>
Ad&e -fty,and Zip V V ft. ON
Physical ss, U
b
21.REMARKS 14,J L't ke-T
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
IDO,
(if well field,one lat/long is sufficient) 22.Certification:
3(o 3 ' if N 0,3'0" j-7'J--3 W
6.Is(are)the well(s):ArPermanent or OTemporary Signature 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: OYes or )tNo ISANCACO2C.0100oi-15ANCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information Ad 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 welIdetails:
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 ceded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ? 1 24.SUBMITTALINSTRUCTIONS
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 ifdifferent(example-3@200'and 2@100)
10.Static water level below top of casing: To —(ft.) 24a. For All Wells: Original fonJ I i to Division of Water Resources (DWR),
I Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use 11,
Eltoff 24b.For Injection Wells:Copy to DWR,Underground,41jection Control(IUC)
11.Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
-M
AIR ROTARY
12.Well constructiodmethod: 24c.For Water Supply and Open_L�06p Geothermal Retdrn Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environmental health department of the county*herdinstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD' 'Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) 3 1/2, Method of test:
13b.Disinfection type: 70%HTH Amount: 3 Oz DATE SITE VISITED:
*yj + VISITED BY: zz a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ) Revised 6-6-2018
I PP C AW E