GW1-2021-02393_Well Construction - GW1_20210722

'mal Use 011,ki:
Well Contractor Naine FROM TO I)TSCROTIDU
0 LA 5'C 113 3 6"
NC Well Contractor Certification Number OM
0 ERRASPIG(for multi-cased
N&M 0 DM JgTr
YADKIN WELL COMPANY,INC. "vol T I TR MATMIAL
ft- 1. ft. 1 1 in.
I
Company Name tIr)C�8'1';"�'
16.INNER CASING OR TUBMIG(geother at dosed-loop)
2.Well Construction Permit 71 PROM TO DIAMETER TMCIGqESS MAIIERML
List all applicable Well construction permits(i.e.UIC,County,State,Variance,etc.) 41 ft. S in.
Vcf In- SDR';�% +1VC_
3.Well Use(check well rise):
17.SCRIZ:14
Water Supply'arell: 1-1-Rop"I TO D-JAPIETER SLOT SIZE TEM11NESS HATERIAL
DAgricultural 0MunicipaUPublic it. ft.
DGeothermal(14eating/Cooling Supply) Igesidential Water Supply(single) -it
ft. in
DIndustrial/Commercial OResidential Water Supply(shared) 13.GROUT
DIrrigation DWells>100,000 GPD FF.0'1%1 TO MATEERTAL FAUILACEATMMT NMI-,,THOD&AJv10U111T
Non-Water Supply Well: ft. ft. Flote P1 Ppyrea :3'120 r-,SS
DMonitorina ORecovery
LJ "' ft' Ptmq0s!
Injection Well:
ft. 7 ft.
DAquifer Recharge OGroundwater Remediation 19.8i=lGRAJrE L PA-C (dapplictible)
DAquifer Storage and Recovery OSaliaity Barrier FROM TO MATERIAL EMPLACEMENT - TH1 D
OAquifer Test DStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft• ft
bGe-othermal(Closed Loop) a OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) PROM TO DESCRIPTION(color,hardam,soillrock type,grain size,etc)
0 ft. -76 ft'
56e f
4.Date Well(s)Completed: 10 J.D1 we -l& it- q.3o% Cranar
H ED#PAO 'I ST
ft ft.
5a.Well Location: Phone
4 C,(,.*,"5 C-a !9A4 Y"
�Owner Name V Facility]D#(if applicable) ft. ft.
14A 41L 0 1V
Physical Address,dlAind 4p ft' ft
21.RVVIARKS
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ceffification:
J_G b'3, 7.5--0 3 N XA �0.04 3 :L2 3 W
A A 4 A Jzgki=
6.Is(are)the well(s): Oermanent or ' OTernporary Signatqe-of Cerfified Well Contractor Date
By signing thisforny,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or�/*9 0 15ANCACO2C.0100or15ANCACO2C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary-,
drilled- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0
For multiple wells list all depths itdifferent(example-3@200'and 2@100) (ft) Submit this GW-1 within 30 days�lof well completion per the following:
10.Static water level below top of casing: _)0 24a. For All Wells. �111rUIW LULM.to Division of Water Resources (DAIR),
(ft') Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" 1
11.Borehole diameter: (in.) Bit Off* 0 Ll 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY on For Water Supply and Open-LoopI Geothermal Return Wells:Copy to 1he
(i.e.auger,rotary,cable,direct push,etc.) county environmental health dep"ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DW[;,CCPCUA
Permit-Fro T611 C,Raleigh,NU 27699-1611
13a.Yield(gpm) Method of test: gram,
13b.Disinfection type: 70%HTH Amount: LJ Oj DATE SITE VISITED:
VISITED BY:. fll)q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
PRICE