GW1-2021-00098_Well Construction - GW1_20210422

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Page 1
Submission ID#
CONTACT INFORMATION
................................................................................................................................................. .......................................................................
Contact Name* Email Address*
David Horn [e-mail]
Is this a revision to the form you have previously submitted?*
f Yes r No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
...............................................................................................................
Certiticate# Cert Level First Name Last Name Company Name
4298 A CHESTER HORN HORN&ASSOCIATES, INC
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Kibnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
3/26/2021 B-01 B (gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name* Facility ID#
Yadkin Co. Conservation District 19A
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Yadkin 489700093677
Physical Address* Street Address
Weatherman Road
Address Line 2
City State/Pro\ince/Region
Booneville NC
Postal/Zp Code Country
27011 us
Latitude* 36.1573380000 Longitude*80.7267860000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
Formultiplewells Iistall depths ifdifferent surface?
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11.Borehole diameter:
25.0 8"
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
25.0 42.0 Water table-Dam/Pond
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 36.50 1
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
36.50 41.50 2.00
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 33.00 Neat cement Tremie-80 gallons
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
35.00 42.00
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type, grain size,etc.)
0.00 0.30 Topsoil
in feet in feet
0.30 4.00 Reddish-brown,silty-clay
in feet in feet
4.00 20.00 Brown,silty-sand
in feet in feet
20.00 42.00 Gray,sandy-clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 4/22/2021