GW1-2021-00093_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
3/27/2021 B-51A (gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name* Facility ID#
Yadkin Co. Conservation District 21
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Yadkin
Physical Address* Street Address
Helton Road
Address Line 2
City State/Province/Region
Yadkinville NC
Postal/ZZp Code Country
27055 USA
Latitude* 36.0925510000 Longitude*80.7207460000
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 explain 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.)
81.0 9a.What is the depth of the casing from ground
Formultiplewells Iistall depths if different surface?
(e)ample-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
29.4 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
Piezometric head-bedrock
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 60.00 1.25
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
60.00 80.00 1.25
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 54.00 Neat cement Tremie- 125 gallons
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
57.00 81.00
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type, grain size,etc.)
0.00 0.20 Topsoil
in feet in feet
0.20 7.60 Light-brown and red,sandy-clay
in feet in feet
7.60 34.50 Light-brown,silty-sand
in feet in feet
34.50 52.00 Gray,sandy-clay
in feet in feet
52.00 56.80 Gray sand with some black
in feet in feet
56.80 81.00 Gray, gneiss, hard
in feet in feet
21.Remarks

Bentonite seal-54.0-57.0 feet
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