GW1-2021-02629_Well Construction - GW1_20210809

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WELL Cl( NST RUMON RECORD(GW-1) For Internal Use Only: 4
1.Well Contractor information:
FROM TO DESCRIPTIO14
Well Contract Name 57C
NC Well Contractor CettificatimiNumber I5.oD CASIl\TG formidti'' ivelta'OR IsII4EIt'z£'" caTile= -:'.: ..
Yadkin Well Company Inca FROM To D TPacmvsss 74ATERIAL
ft, ft. i ia. �� fn
Company Name �-—*>`INEHCASIVt 0RTUDING 'eo`tIie'iatialclnsedIoo �"�J
2.WellConstructionPermit#­ ACd$Q�'07 FROM To PIAMEM xmtDztvass MATERIAL
List all applicable well construction perortts ji.e.Ma County,State,Variance,etc.) ft it °' r,
3.Well Use(check well use): f ft m
Water Supply Well: FRam 20 s%oTsrtR TalcxrvFss MATERIAL
AgdcultuYat nMurricipaUPubIic 0 ft. ft lu
Geothemnal(Heating/Cooling Supply) OResidential Water Supply(single)
Industri-Xommercial [3]kesiden ial Water Supply(shared)hrigat ;• : -
.o FROM TO MATERIAL j EbM1 ACEhU=b=TBOD&AMOUNT
Nan-Water Supply Well: 6 ft ft ��* ` xoj!f `
Monitoring QRecovery - ft 3 fL d U
Injection Welk
ft ft
Aquifer Recharge Groundwater Remediation
•19:59MlGR9.VEL70AGrIC if a'"'llcable '
Aquifer Storage and Recovery CMSalinity Barrier FRom To MATF-RT L WMACEMffiYT10MOD
Aquifer Test 0StormwdterDramage ft ft'
Experimental Technology Subsidence Control R ft /
'Geothemal(Closed Loop) LITiacer 20:D]Itif IANGtWtittactcd3Hifiorislsbeetsifneer3s' - /
Geothermal(Heating/Cooling Return [—Other lain under#21 Remarks) MWM To nxscaxrTlox(color ha:aanss,sor7lmck w
0 ft
4.Date Well(s)Completed:Z WeIIID# .1 ft � ILft fL
+G p
5a.Well Location: Phone ntlmbel 3 3 "' i"0
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FaMIULyfQwnerName Facr1rty1D#(rfWlieable) ft ftPS
ft ft
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tit, .,
Physic}}alAddress,Ctly, ad Zip �^ 5FV-3 Q—{,9 � f ft
21:-RF.MARTGS,' -• - = a
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County ParcelT oatgonNo.(PIN} n
5b.Latita d
de and longitude is degreeslminntesfseeoads r decimal egrees:
(ifvmli field,one laMong is sufCiont) 22.Certification: �^'J
3 5 —W rczzl
a+-air
6.Is(are)the well(s)OPermanent or Temporary Sr of Co d ellContracixs Date
By signbig this farm,I hereby certlfy that the well js)was(were)constructed in accordance aE ,
7.Is this a repair to an erosting well: E)Yes or Wo with 15ANC4C 02C.0J00 or 15A NC4C 02C.0200 Well Construction Standards and thin a
Jfthis is a repair,fill out known well construction information and explain the nature afthe copy ofthis retard has been provided to the well owner.
repair under#21 r'emada section or on the back of this form, _pr
23.Site diagram or additional well details: (/ \
S-For GeoprobetDP'T or Closed-Loop Geothermal Wells having the same You may use the back ofthis page to provide additional well site details or well
construction,only 1 GW-1 i needed_ Indicate TOTALN LAMER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' lL'4- (ft) 24a. For A11 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdiferent(example-3@200`�and
2@700) construction to the fdllowing. C)
10.Static water level below top of casing: rt7r/• (ft.) Division of Water Resources,Information Processing Unit,
Jfwaterlevel is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699 I617
IL Borehole diameter: (in.) Bit cff I/Ift 24b.For Iniection Wells: In addition to sending the form to the address in 24a ✓✓
_ �I above,also submit one copy of this farm within 30 days of completion of well
12.Well construction method, i1 construction to the following:
(ie,anger,rotary,cable,dimctgash,etc) "
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce`Snter,Raleigh,NC 27699-1636
13a.Yield(gpm)�., Method of test: a/(M'- 24c.For Water Supply&Iniectionn We-Us:;In addition to sending the form to
the address(es) above, also submit Jove copy of this form within 30 days of
13b.Disinfection type: HTH Amount: WR14S 4?1p a2' completion of well construction to ih e county health department of the county
where constructed. ;AV �(� !
3
For GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources Revised 2 22 2016 nAl
Date Sih--VititAd .-�7-d o bye !6B i► i l� .a a •��
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