GW1-2021-03193_Well Construction - GW1_20210615

Internal 1:
Well Contractor Name FROP. TO DESCRIPTIWI
47 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'-ells)OR LMR(if applicable)
YADKIN WELL COMPANY,INC. FROM To T,R I THICHNESS MATERUL
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit FROM TO DLAUVIrTER THICENESS MATERIAL
List all applicable well construction permits(le.UIC,County,State, Variance,etc) ft- It 6'1* Alc
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROT-4 TO DIMJELTER I SLOT SIZE Tff109iESS HATERLAL
DAgricultural OMunicipaUPublic ft. ft
DGeothen-rial(Heating/Cooling Supply) )(Residential Water Supply(single) ft.
in.
ClndustriaYConimercial DResidential Water Supply(shared) T _­1 I
DIrrigation E]Wells>100,000 GPD rRolpi TO NIATERVIL UUPLACENINT NWTHOD& %JIOUP1T
Non-Water Supply Well: 0 ft- 3 & tj 6,mV-1 '12
_&-" 0 r , 3—
DMonitoring DRecovery 3 ft- L4un,'l, m A Xk
Injection Well:
DAquifer Recharge EIGroundwater Remediation
19.SeVID/GRAVE L PAC (if applivable)
DAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL ED.-IPLACEMENTAWTHOD
DAquifer Test OStormwater Drainage fr ft.
DExperimental Technology OSubsidence Control
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
DGeothermal(fTeating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eM)
4.Date Well(s)Completed: Well EN tf,4,0,4K,9 3 — oft. ft.
.2 ft- ft. _S&4,S-hA6 ZkAAX/J &A
Sa.Well Location: Phone #72 ZZ 4/Y-410 7 5 11 a fr. WL ft.
, nip5 74 e 4/'e— y 1-k 4 P 1C
Facility/Owner Name Facility M#(if applicable) ft.
CAE e_r Pew6 /-,u ft.
ft. REGEVED.
Physical Address,City,and Zip ft
21.,RE NJAJW 2021
County Parcel Identification No.(PIN) 11&Uy 6
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Information Processina Urtit
(ifweH field,one lattlong is sufficient) 22.Certification: DVVR Secuon
N S-o 4(q I;P
6.Is(are)the well(s): ,Permanent or OTemporary Siggature of Certified Well Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: 01(cs or ;4q0 15ANCACO2C.0100or15ANCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information ofid explain the nature of the of this record has been provided to the well owner.
repair under 921 remark section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additi6nal well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yd'u may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0� (ft-) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths it'different lexmple-3@200'and 2@100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 —(ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: 1, oeg
11.Borehole diameter (in. 24b.For Injection Wells:Copy to0WR,Underground Injection Control(rUC)
:
— -4/0 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
(ie.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
13a.Yield(gpm) Method of test: 41,r Permit Program,1611 MSC,Raleigh I,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Z' Oz DATE SITE VISITED:
/vI VISITED BY:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018