GW1-2022-08919_Well Construction - GW1_20220912

✓,- NTROSdd ��-� r nternal UseOnly:ELL CONSTRUCTION RUCI C I,. .
1.Well Contractor Infortonildn
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Well Conha ;Name
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YADKIN WELL COMPANY,INC. " ; ,' + a HFROM�xTo �� "DIMIItYBR' - TBTClarB85 MATZWAL
ft ft. in. �..
Company Name -m Q Q 16.Il�►R CAMG OR TUBING eothermal dosed loo
2.Well Construction Permit#: 5133-! FROM To Durso TMCK nS I rz&TMAL�r� i1
Lis/all applicable well construction permits(Ce.=COI my State,Yarlance,etc) �� it �t 1 1II' S Q-L V(/
3.Well Use(cbeckwell use)' �T fr m Cr
17.SCREEN
Water Supply Well: FROM o DIAMETER I SLOT SUE I THrctavEss I MATERIAL
❑Agricultural ❑Municipal/Public fr. in.
❑Geothermal(Heating/Cooling Supply) Oesidential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑ ' ation ❑Wells>100,000 GPD I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 3 ft. -"h �,1e Gl�1 l t.r' /
❑Monitoring 13•.
Injection We1L a,r;. 9 g, ft.
❑Aquifer Recharge oundwaterRemediation 19 SAND/GRAVELPACK(if a liable)
❑Aquifer Storage and Re,&u 1 29ralinity Barrier FROM To MATERIAI. MENTMETHOD
❑Aquifer Test ,wpS�tlixiier Drainage
❑Experimental Techt��ogy p`�'i + 7Subsidence Control ft ir.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIlVGLOG attach additional sheets if necessary
FROM TO DFSCRrMON eolor,bardneu,soilfroek a mn size,etr
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
163 ft' ft ed
4.Date Well(s)Completed:� Well ID# — ft. ft.
/- ft ft
5a.Well Location: PhOt10 6
�` `"0 ic ft it
Facility/ Name �ro-
Facility 0#CifftftdwI its
y6cal Address, ,and Zip �8��3 ft
Fh it
21.REMARKS "w"4$
County Parcel Identification No.(PIN) Q S/A? t S G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): j ermanent or OTemporary Signature of Certified Well Contractor Date
(1 By signing thisform,l hereby cert�that the well(s)was(were)consGvMed in accordance with
7.Is this a repair to an existing well: a Yes or i°JNo ,�Z � 15ANCAC 02C.0100 at ISA NCAC 02C.020D Well Construction Standards and that a copy
If this is a repair,fdl out known well consimcHan information and explain the nalt�re of the afthis record has been provided to the well owner.
repair under#21 remarks section or on the backofthisfonn. 23.Site diagram or additional well details:
' You may use the back of this page to provide additional well construction in
6.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same fo construction,only 1 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.SUBMTr'rAL INSTRUCTIONS
l
9.Total well depth below land surface: �� (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if djBerent ft=mp/e-3@200'and 2Q1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: A) Information Processing Unit,1817 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing use 11,1. Cl
11.Borehole diameter D (im) Bit Off: �s / 03 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 Return Wells:Copy to the
(Lt.auger,rotary,oable,direct push,etc.) county environmental health department of the county where installed
Q� m FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
e G Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test: ct 'f !
o DATE SITE VISITED: s
13b.Disinfection type: 70/o HTH Amount: OZ
Psi ' _ _ VISITED BY:
Form OW-1 _ ., North Carolina Depafinent of Environmental Quality-Division of WaterRasources Revised 6-6-2018