GW1-2021-01465_Well Construction - GW1_20210305

t?'ell C,mtl,.co,r•3a,;r. �.._� _ _._._.�--- --- _ ..__ __ -_ ___.._ __.._
NC Well Contractor Certification Number
15.OUTER CASING for m»lti-casell vitells)OR LUITER(if applicable)
YADKIN VVELL COMPANY,INC. FROis Ti I �2F_t.•ars(i 1 1­rHFC_1213SS tdATEyAA
r�r' ^� _ it. ft. I E in.
Company Name t
t e t 16.17V1�tER CASING'OR s UsBOI ( e°iaeccaal closed-IGOn)
2.Well Const9 as San Pera,ait# `� r3dJrra TO DIA[r1GTER 'T11ICIa'IT 5 k•1A T rR,I_L
lrrl all applicable Well c0mhrc11017 permils(i.e.UIC:C011171)1,Stale,Parlance,elc.J ) 9� �
64F'
• i
❑itt,�c4tC s _._ __—______._.._._. Clv.i, ' ^..100t 0(li)!—r...D.
01v4011ita rite Oh.eco--eTy --1
❑A�uif�l l..char�a ❑C,ol_l,d�-eater Rervdisi;an � ( ( � __—_ �
❑A rlifc,`itoraac and Recove, Sa 1>7 1 f L _(it c ]t' '
q T ❑�chiliiy aR'ier r , T v 1 i_r,__tS_ti I .i.1r2: C;_ri'4T,t1_T i_,:
❑Aquifer Test ❑Stormwater Drainage �—
OExperimental Technology ❑Subsidence Control ft. ft.
❑Geothennal(Closed Loop) ❑Tracer 20.DIRLI,I FDIC LOG(attach additional sweets Unecssary
FRO314 TO DESCRIPTION(color,hardness,soft/..-ock t-•-se,Brain size,Bic.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 10 ft. ft. ��t
4.Date Well(s)Completed ,- Well ID# L.('"5"
Sa.Well Location: Phone #3X,-`7a7-�(F;F
�'t✓u e, 4- C CJ roc i C'-- i' rl6( &sc dt '4 t be C(J ft. ft. *1 t w Cr� nt, Art f-L'
Facility/OwnerName ---- Facility ID#(if applicable) ft. /yi I g
ft. J�
Pbysiica_l''Add�rPe ss,dq and Zip ft. Y..
1/>(J 6 f ke S 21.f ERIr�r�1fS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification. Information Processing Unh
77 3 N 9f ';' I/, c/��r �, —� D11U ec.ion
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this fold),l herby certix that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 194 A1CAC 02C.0100 or 15A NCAC 02C.0200 flrell Construction Standards and that a copy
f this is a repair fill out known well construction information and explain the nature ofthe of this record has been provided to the welt oumer.
!
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional aver)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 NUD.IBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: P� Z 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 80 2 (ft.) I
For inultiple wells list all depths ifdiffie ran I(example-3@200'and 2©100') Submit this GW-1 within 30 days of well completion per the following:
�� {ft 24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: ) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
Ifwaterlevel is above casing,rise
�o- Bit Off: �t 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Openioop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY LLS ONLY: 24d.For Water Wells producing Lver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,iNC 7.7699-1611
13a,Yield(gpm) Method of test: o.b �
f
13b.Disinfection type: 70°/n HTM Amount: OZ DATE SITE VISITED: t' '���- Z
� ! k
VISITED BY: 0'313
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revi G-201 S
�_( ' [ !
w� tafT 3 ti _. r* 4 -a!.