GW1-2021-02717_Well Construction - GW1_20210809

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Well Contractor NameTZ
� Ti;Ci.l O C vZ� r TiTi.•il
ft. ft
NC Well Contactor Certification Number P 15.OUTER CASING for multi-cased wells OR LIIVEIi (¢a plicable
YADKIN WELL COMPANY,INC. �r FROM zo MASTER THICItNEsS TERIAL
N ft. ft. in.
Company Name � �' 16.INNER CASING OR TU13ING( -othermal closed-loop)
2.Well Construction Permit#: i " -g FROM To D1n AM,TER TRIMNESS XAL^R.RrAt
List all applicable well construction permits(ie UIC,County,State,Yoriance•etc) 4-P.
6 ft, fiap-mul to c,
3.Well Use(cteckWeil l,se): ft. ft in.
i
li.3Ci'.�,PI
®later Supply Well: Fe_OLi 'O SLO-I S zil TiLC1ai 50 r:•1::TiPI-ILL
❑Agricultural ❑MunicipaUPublic ft. ft. in.
❑Geothemial(F-ead*Cooling Supply) wesidential Water Supply(single) it ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) lam.Cr.Ufl1T
❑Irrigation ❑Wells>100,000 GPD MON To MATERAL EMI'LACsriTNT P.•1E.THOD L-AlrIOUNT
)iron-Water Supply Well: ® I!• ft B �z
❑Monitoring ❑Recovery ° P, ft. s ! .
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation
19,SAPID•/GPAACL PACK(if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier F-P_OM TO MATERIAL rROLA_CiTIEW RRE-MIOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Expetimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attacb additional sheets if necessa ,)
[]Geothermal(lieating/Cooling Return) ❑Other(explain under#21 Remarks) FRORY TO DESCRIPTION color,hardness mailtrock grain sa etr-
��� C> ft P ft. o9s°f
4.Date Wells)Completed: -JhP� Well ID# - ft• ft ®C S- t
ft ft 1.
5a.Wel[Location: Phone ��®z° ��`� �� l
ft. J t�Pl it
FacilitylOwnmkame - Facility ID#(if applicable) ft ® ft
Physical Address,City,and Zip q ft IL
y 21.
Comi J v Parcel Identification No.(FIN) .�®�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,ona laf/long is sufficient) 22.Certification:
Z -1 1`1y. %a N Y'l . EV, 76 J"Y7')�E- .0-
6.Is(are)the well(s): Mermanent or ❑'Temporary Sigaahue of Certified Well Contractor Date
By signing thlsform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ]Yes or 10 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Imown well construction information d mplain the nature of the of this record has been provided to the well owner-
repair under A21 remarkr section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/IDPT or CIosed-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. Intricate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 0 24.SUBMITTAL INSTRUCTHONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 da s of well completion per the following:
For nnultiple wells list all depths ifdifjerent(example-3@200'and2(a)100� y p p
t 24a. For All Wells: Original:form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ff) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
Ifwater level is above casing,use ��P
Bit Off: 24b.For In
iection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter:_ (�) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For®later 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 GPID:Copy to DWR,CCPCUA
13a.Yield(gpm) 11 Method of test:
Permit Program,1611 MSC,Rrileigh,NC 27699-1611
� f
13b.(Disinfection type: 70%HTH Amount: QZ DATE SITE VISITED:
VISITED BY: U� 4
Form GW-1 _ _ North Carolina Department of Environmental Quality-Division of Water Resources Revised 662018