GW1-2021-02430_Well Construction - GW1_20210615

7­
C-"l Jst r ; -
I J -7 C.i'I=
Well Contractor Name H.C.P.1 TO DZscag'T10i)
3 0 3 G A
4C Well Contractor Certification Number 16301,-, It--%/z-i
15.OUTER CASING for multi-cased wells)OR LINER(ifaj, cable)
YADKIN WELL COMPANY,INC. FROM I To ,
rrW I MAIMUAL_
CompanyName I I �iij_
41 16.INNER CASING OR TUBING( other al,dosed-loop)
2.Well Construction Permit#: FROM TO - -I DIAME1 TJZR� I IM(XOMSS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Variance,etc.) 411'- 11 ft• in. mu Z/ prc,
3.Well Use(check well use): ft.
IL in.
Water Supply Well: 17.SCPEZ�l
F[ROT11 TO DIAN-7-TER: SLOT SIZE TERCMIESS HATErCal,
OAgricultural OMunicipaUPublic it, ft.
DGeotherinal(HeatinVCooling Supply) WOesidential Water Supply(single)
ft. in.
01ndustriaYCommercial DResidential Water Supply(shared)
a T
OIrrigation OWeUs>100,000 GPD 17RON1 TO I WjEJUAL EtrLPLACU-IEENTHETIHOD&ATIOUNT_
Non-Water Supply Well:
DMonitoring oRecovery 3 ft- Z If It yz
fniection Well: ft. I
ft
OAquifer Recharge 00roundwater Remediation 19.SAND/G I LPACIQifapplica r ble)
DAquifer Storage and Recovery oSalinityBairier rpolvi- (A
TO MATE RIAL E111PLAM.`LM*4T R-M-TE10D
DAquifer Test ElStormwater Drainage fL ft.
OExperimental Techn6logy OSubsidence Control fL
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal MeatinglCooling Return) 00ther(explain under#21 Remarim) TROM -TO DESCRIPTION(color,hardness,soft/rock type�grain sae,etr-
S )
D ft' S®a .
4.Date Well(s)Completed: .5 1-Z-I Well 1D# J1 ft. I it) fL WLA" Lit
Sa.Well Location: Phone #3-36--6ry-72-20 HO ft X0.2" .. Stfrf- GrcA-c
I te. Ecz 4-+
Facility/owner Name Facility ID#(ifopplirabl ft. fL
6 S
00' 1 9
Aurnol A Iko k Jet e-
- -4 vau-71s tu fL
Physical Address,City.azid Zip ft ft
I 1 11 IN I
AIXem.1- __L 2L REALARES 1
kiriit
County -7 Y
Parcel Identification No.(PIN) Infoft-.2"Llon PIOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweu field,one lawong is sufficient)
22.Certification:
91C. 36 N 2 ' lk W /Yzj��
6.Is(are)the well(s): EvImanent or OTemporary Sfguature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: OYes or 244/0 15ANCACO2C.0100or15ANCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and nature
explain the na of the of this record has been provided to the well owner.
.P
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop geothermal Wells havingthe same You may use the back of this page to provide additional well construction info
construction,only I QW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below-land surface: '76 0 -(fL) I
Submit this
For multiple wells list all`depths#-&fferent I`kzample-3@200 1 and 2@100) GW-1 within 30 days o I twell cam I�npletion per the following:
24a. For All Wells; Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 6o (ft.) Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
L
11.Borehole diameter: Bit off: 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-L cop 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 100,000 GPD:Copy to D CCPCUA
Permit-Prog=,1611 MSC,Raleigh,�'N(;27699-F I I
13a.Yield(gpm) Method of test: Oz
DATE SITE VISITED:
13b.Disinfection type: 70%HTH Amount: L
VISITED BY:
Form GW-1 North Carolina Department of Environmental a -Division of Water Resources Revised 6-&2018
10W.Ma Q If IV a•s1