GW1-2021-02705_Well Construction - GW1_20210809

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Well ContractorNauneN- -_- --•-- w ---- \- i•7•.�•i.l TO �....__��efr•i�
30 36 A l3 ft. i3• ,t. s� v 780- SGd
NC Well Contractor Certification Number �\ �'�°G rt�� ;V
�OS1 GJZ' 15.OUTER CASING for mull-cased wells OR LIVER(if a ticable
YADKIN WELL COMPANY,INC. \�'�� ��� FROM To DIAM�TGR THICTacis5 TERIAL
ft. ft. in.
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Company Name G-L'd v� _ I a,(, X- 16.INNER CASING OR TUBING(Ircothermal dosed-loop)
2.Well Construction Permit#: Cb J -C - W,0 14n-0 161/ FROM TO DIP MrTRR THICENESS MAUMUL
List all applicable well construction permits(i.a.UIC,County,State, Variance,etc) IL ft. S[ aft• e in.
v ``Z It /7v
3.Well Use(chectc w6l use): fr. ft, in. �i
Water Supply NVell: M 5C'1'1s%i I
F£-Ot,I TG DfAP:IaTc:2 I SLGTSfZE TiyrClGit:SS i•.7TFini:L
❑Agricultural ❑MlunicipaUPublic ft. ft,
❑Geothermal(14-eating/Cooliug Supply) ``Residential Water Supply(single) et. ft.
01ndustrial/Commercial ❑Residential Water Supply(shared) Id Gr.OUe
VIrrigation ❑Wells>100,000 GPD MORI TO TI TERrAL EMP ACEUENT rf✓THOD r•A1:I0oN
Non-Water Supply Well: ti. ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.uAI*1D/GP.t11r31,PACK(iF aprlicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier F•eOMt TO IYIATERIAL iP.IPLACEr:ILEIri DMTHOD l
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) TROn2 TO DZSCRIPTION color,hardness,soil/rock type rain size,etc
9 Z ft. ft. 0
4.Date Well(s)Completed:6- `' Well ED# w b 3 6�v ft• g ftzm'a �� r P
5a.`�/ Location: Phone 7 ft. &N fL S •� 42n.dowu
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6k ? lyd«(a (Dc k 214e e, ft. ft. 0
fL
Physical Address,City,and Zip
si ft
`n -I-Furl 21.REMARKS �
County ( Parcel Identification No.(PnN) IDd1 ' 2'02�✓LGCJ ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: , , G 2
(ifwell field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): tsyr•ermanent or ❑Temporary Signature of Certified Well Contractor: Date
By signing this form,I hereby cergfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes 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 Imown 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 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 J is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: [ J 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: Ella- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd fjerent(example-3@200'and 2@100')
�UU 24a. For All Wells: Original form to Division of Water Resources (DWR),
ft 10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"" Qt�
11.Borehole diameter: V (in.) Bit off:-, 7 7.� 24b.For Injection Wells:Copy,to DWI;;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 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 DWR,CCPCUA
(' t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method oftest: 11 A A.(tr
13b.Disinfection type: 70%HTH Amount: G OZ DATE SITE VISITED:
I I\�
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourc s Revised 6-6-2018
PRICE ,
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