GW1-2021-02397_Well Construction - GW1_20210722

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Tell Coiifrawtor Name I
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3 0 3 ft. ft. Li I i I
NC Well Contractor Certification Number .) j, I
io \31A 15.OUTER CASE\IG(for multi-cased*ells)Olt LINER if applicable)
YADKIN WELL COMPANY,INC. FROM To MUM TER THICICNESS I MATERIAL
Company Name ft. in.
V%�O�%T,3 J Be :��7
16.INNER CASING OR TUB INIU(tmather.al closed-loop)
FROM TO DIAMETER THICENESS I MATERIAL YL)
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2.Well Construction Permit#: M - -_ I ft. in.
List all applicable well construction perm(i.e.UIC,County,State, l/arlance,etc.) + 0 SC-4 q10 6iu 3-fee 'ehl
3.Well Use(check well use): ft. ft, i in.
i
Water Supply W 17.SCREEN
ell: _J_S�ZE-ITZIC191ESS I P.A.''70 DIAPIETER
DAgHcultural Aflunicipal/Public
DGeothermal(Heating/Cooling Supply) DResidential Water Supply(single)
DIndustrial/Commercial DResidential Water Supply(shared) id GPICAUT
oh-rigation DWells>100,000 GPD FRO11.11 I TO il.,IATMLA�, E11 UP LACEUPIT HETHOD�_,AJJOU11T
Non-Water Supply Well: f!. Am.* IQd,-
Dmonitoring EIRecovery ft. ft. ViA +rtf,.;f- P�Ao _YJ
Injection Well: ft. ft.
oAquifer Recharge DGroundwater Remediation
w 19.SAilril/cRAIIEL PAC (if applicable)
DAquifer Storage and Recovery OSalinity Barrier FROAT TO I W-TERIAL EMPLACEP.-LENTa-MTETD
OAquifer Test oStormwater Drainage
OExperimental Technology oSubsidence Control ft ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Ileating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
0 40 it.
4.Date Well(s)Completed: S- 12- 209efl][D# 10 q 0ft 70 ft. Arvc4ur-J
Sa.Well Location: Phone # ?27- 773-a177 70 ft. a 10ft. 144 6AGule-
Za, 110ft. (10ftMdS IsAil
Facilit;/Owner Name Mility ID#(if applicable) 240 ft.
J// 1?,Ck S-d U ft' SW-d Ad A RJR 1-4-
ft
Physical Address,City,and Zip ft- 6ol HAZA
WR(Ad.L(4 CA 21.REMARKS
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County Parcel Identification No.(PIR) R"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 40 A
(if well field,one lat/long is sufficient) 22.d'tifiration:
N Eta 92 12 - .2 02
6.1s(are)the well(s): 4rmanent or OTemporary Sifoatare of Certified Well Contractor Date
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: 0yes or *0 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standords 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 Geoprobc/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: 24.sumnTrAL iNmucnoNs
9.Total well depth below land surface: y 0 1 -(ft.) Submit this GW-1 within 30 days.of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: '70 , (ft.) 24a. For All Wells: Original form to Division of Water Resources (D'%a),
lfwater level is above casing,use - q Information Processing Unit 1617�I MSC,Raleigh,NC 27699-1617
e-B,tOff: ff*,&,.23q 24b.For Injection Wells:Copy to'DWR,Underground Injection Control (IUC)
11.Borehole diameter: (in.) 7*71W Program,1636 MSC,Raleigh,NC 2 699-1636
12.Well construction method: AIR ROTARY 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,600 GPD;Copy to DWIZ,CCPClJA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) co Method of test: 11it &;r
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
M 6 4 Sao' Ai 6 1 1),Co,, 10 iD 1 h: &m VISITED BY:
Form CrW-1 3w, Pi.,- North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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