GW1-2021-02696_Well Construction - GW1_20210809

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Well Contractor Name r�R0i11 TO D SC_UME-1
C, � � 2/d ft. 2/�
3 4 , - P c °r - 3 s ft ft
NC Welk©tractor Certification Number �.fl���F' 158 Oi1TER CASING for multi sed welts OR LAVER a licable
YADKIN WELL COMPANY,INC. ��^,�� O FROM To DIAMLTER THIC[ TERIAL
Company Name &CA t�04 ��t/�� 16.INNM CASING OR T[IBING(geothermal dosed-loop)
2.Well Const fiction Permit#:Z s®ey-Al d1/ 1C s 0-y�V ® FROM I TO I D OM= I
T,MaM SS MATRRTAL
List all applicable well construcilon pamils(Le.=,County,Slate,Pationce efc.) + r la 7 ft. 14 JlJ�• �1 PAC
3.Weil Use(cheer well L:se): ft. ft. in.
Water Supply We[!: 17.SCIL LPi
e e 01r1 TO DIAMET2.1 SLOT SIZE THiCQi_So t;.1-rY
❑Agricultural OMunicipWPublic it. ft. in.
❑Geothermal(Heating/Cooliag Supply) SKsidential Water Supply(single) �n f
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.Cr.Ull'e \
❑Irrigation ❑Wells>100,000GPD MON I TO n9A,aRrAL ErtPLACEPM-NTMET90D Al.-10UNT <�
Non-Water Supply Well: t A
i �iA✓.
❑Monitoring ❑Recovery 7 it .?S ft. �..7`a/ S ,► /u
Injection Well: ft ft
of
❑Aquifer Recharge ❑Groundwate.rRemediation 19.SA1`II}/GFAl'EL PACE:(if ao licable)
OAquifer Storage and Recovery ❑Salinity Barrier F-Ponl TO MATERIAL EMEACcr.-MT IV=- HOD �
❑Aquifer Test OStormwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(geating/Cooling Retmm) ❑Other(explain under 421 Remark) FRoet To p DESCRIPTION color,hardness santrock aae,etr
� . Q Q ft //O ft �rV
4.Date Wells)Completed:7 Well w#AA0��� ` //8 ft , a a ft
5a.WellLocation: •Phonkr Q -SX 1-7gk6 a©� ftZzs ft =I /e� . --�
lA I[.I�aii.� (�, sA )) Zu fl. 12V ft.
Facility/Owner Name rr'' //�� Facility lD#(if applicable) is ft ft � G
ft ft
Phy/siicc�al Address,City,and Zip
V-"al"i l 21.REMAR'KC
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): IldPermanent or OTemporary Signature of Certified Well Contractor; Date
By signing thisform,I hereby certrfy that the well(s)was(were)constructed inaccotdmtu with
7.Is this a repair to an eidAng well: OYes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy (�
If this is a repair,fill out lmown well construction information and ezplabt the nature of the of this record has been provided to the well miner. ` -
repair under 921 remarks section or on the bark of thisform.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovd in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 A (ft)
For multiple wells 1W all depths{{different(e=ple-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: �0 ( ) 24a. For All Wells: Original farm to Division of Water Resources (DWR),
Ifwater level it above casing,use
"++" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (� (in.) Bit Off:J 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Retnrn Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc-) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 160,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) Sib Method of test: re'sf 4 L P Pit Program'1611 MSC,Raleigh,NC 27699-1611
1zt*41c/
J�8 OZ DATE SITE VISITED:
13b.Disinfection type: 70%HTH Amount:
A& & VISITED BY: - 0-19
Form GW-1 ��r North Carolina Department ofEnvironmeatal Quality-Division of Watcr�Reso°rces Revised 6-6-2018