GW1-2021-02425_Well Construction - GW1_20210615

i �
Well Contractor Name o. ' rROP.I TO
3 n N t J a.-o ft.ft. e-
+ fL
NC Well Contractor Certification Number I I J 20�1
J U N 1 15.OUTER CASING for multi-cased wells OR LINER E a p6cuble
YADKIN WELL COMPANY,INC. aRon2 zo In1l4EZER ztlrcICNass TERIAL /
c U 1111
Com an Name IPs Orr"U
p y �'y(R SpCYIGD 16.BNER.CASING OR TUBING( thermal dosed-loop)
2.Well Construction Permit#: 3 C-, FROM TO Dm-n-mTER TB[Fa >;SS MAz?RIAz.
List all applicable well construction permits(i.e.WC,County,State,Ym•tance,etc.) 4-1 ft• 6' ' t in
3.Well Use(checlt well use): ft. ft t�! in.
Water 5npply Well: 17.SCI EZl 1
rROL5 TO DIP.r.-ETE;i SLOT SIZE TH-1CT_4i=Ss r.lATE -L
❑Agricultural ❑Municipal/Public ft. i ia•
❑Geothermal(Heatini/Cooling Supply) ktesidential Water Supply(single) f ft im
❑Industrial/Conunercial ❑Residential Water Supply(shared) Id.GROUT
❑Irrigation ❑Wells>100,000 GPD record TO r.IATnA>, EMPLACshrr'NT M01HOD c aSIOUNT
Non Water Supply Well: ® tt. 3 ft. 814 ro
012onitoting ❑Recovery • Aft• via Puiry /
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAJ`Iiti/Gtiatll'EI.PA CK(if ap66cable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO➢I To MATERIAL EMPLACEl:M1rr METROD
❑Aquifer Test ❑Stormwater Drainage & fL
❑Experimental Technology ❑Subsidence Control It
❑Geothermal(Closed Loop) ❑Tracer 21T.DRILLING LOG(attach additional sheets if necessa •)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM zo DL+SCRIPTION eater,hardness,seiureetr a m sae etc
r 0 ft. .Z� fL l�
4.Date well(s)Completed:S 3-Z( Well MV "'7 a S-fr- 62. ft. S
Sa.Well Location: Phone
2 f- f- �vR
Facility/�Own(crr Name, ,e1 Facility-/M#(if applicable) q R R'
fL ft.
fL
Physical Address,City,add Zip R
1 21.REMARKS
44-s%*--i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutcalseconds or decimal degrees:
(ifwell field,one lat4ong is sufficient) 22.Certif�ca'on:
3 54 Y4e74t N �D �. 7, 3®?S w � �_ S- a {.
6.I,(are)the well(,): *Permanent or ❑Temporary Sigeahue of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or (0 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the»at=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 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 1 OW-1 is needed. Indicate TOTAL NUMBER ofweIls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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 ifdijjerent(example-3@200'and 2@100�
„ —0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above cosbig,use
i
(in.) Bit Off' 6,o lk 24b.For Injection Wells:Copy to DWR;Underground Injection Control(IUC)
11.Borehole diameter:
i Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well constructionmethod: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.sage,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 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gprn) Method of test:
13b.Disinfection type: 70%HTH Amount: 6 OZ DATE SITE VISITED:.
'd rk VISITED BY: U 1
Form GW-1 North Carolina Department of Envimumental Quality-Division of Water Resources Revised 6-6-2018
��- o/�6