GW1-2021-00856_Well Construction - GW1_20210305

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Well Contractorlq a FROM TO DESCRIFTIO111
NC Well Contractor CertiticztionNumber 6s-ft Ir 7 ft �fil �.rf 1� rf�
15.ODTER'CASING furmnlfi=cased wells ORL'INER rFVa 12'
•7Yadkin Well Company Ince FROM To DUMB TH
ft ft
Company Name :..
••:16;INN1;'RC.�:SIl7G`ORTIIBING •eiitlieima-I closedloti •..->-�•= -• = _
2.Well Construction Permit#: FROM TO DIAMETER THI(HIESS MATERIAL
List all applicable well construction peindis f.e.Ufa County,State,Vanance,etc) L '7 ft-
3.Well Use(check well use): ft ft is
YVater Supply Well-. it:SI. RFnT:._
FROM I TO I DIAMT'TR'R SLoxSm THIC sS lfh_7ERLaL
r Agticultiral nMunicipaUPublic ft, ft in
(Geothermal(Heating/Cooling Supply) Wsidential Water Supply(single) ft. ft in.
Industrial/Commercial rjResidential Water Supply shared
Ilrigation FROM To MATERIAL SW- L&CEMENTNMMOD&AMOUNT
Non-Water Supply Well: ft 'ft. 1Qt� I G
:Monitoring [❑(Recovery ft. ft
Injection WeIl: w • Vs"i
ft. ft
Aquifer Recharge n Groundwater Remediation �-+g
19;SA D/GRAVEL iA:CK iFi` dieable V
JEnAquifer Storage and Recovery O5allnityBaIller FROM TO MATERIAL EWLACEMENTMETHOD
Aquifer Test OSturmwaterDrainage ft ft.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) LOTracer Z0:DRILLaVGT OG`attarli'adililioiiel sheet,ifnerrss''
Geothermal(Heating/CoolingRetum.) Other(explain under#21 Remarks) �M xo DESCRIPTION(cnlar,Laxdness,soiUrock a�ansac etc
4.Date Well(s)Completed -'',Wen ID# t%—� � ff Jost
Sa.WeIl Location: Phone number��`9�J-�/�� � (f Sit 7 2- f`
z, 7 ft tl0 ft
Facility/Owner �Name /,f� Facility IL(v ft 70 .fL t?Je01Jd kr �41-
Physical A,ldddd=ss,City,and Zip
/'r ��p— .21:RF.MARTfR•. •e o ,�. _
Comity Pm=11denfficationNo•(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: rn °1 .s
Cifwellfield,one Wong issufcient). 22.Certificatio ;a,3sl '}OS J
3Co 21 3 71 N `Is/ W
6.Is(are)the well(s)iWermanent or UTemporary Si ofCeriifie ell Contractor Date
By signing this form,I hereby cerlify that die we11(sJ was(were)constructed in accm•dance
7.Is this a repair to an existing well: nYes or WNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200)1'ell Construction Standards and that a
If this is a repair fill out Immnn rveQ constructiai information mid explain the nature offhe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisfarm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back ofthis page to provide additional well site details or well
construction,only 1 GW-l-s needed_ Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: P ft
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multple wells list all depths ifdiferent(example-3(a)200'ond2 rQr 100) construction to the following
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 110 (in.) Bit QFf �•d 9'f 24b.For Ini ection Wells: In addition to sending the form to the address in 24a
.Well construction method: A✓ e.,abov also submit one copy of this form within 30 days of completion of well
(i e.ange,rotary,cable,daectpnsh,etc ya -,t construction to the following.) '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: . 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) e)10 Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the funs to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: CUPS completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvimmnental Quality DiDivision ofWater Resources Revised 2-22 2016
Date Site viGLbAd 7 by- � , S A,y a,, i< l