GW1-2021-01851_Well Construction - GW1_20210503

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�.-.—-VF-LL CONSTRUCTION R 'CORD LGW-1jll For Intemal Use Only, '
L Well Contractor Information:
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Well Contractor amo FROM TO DESCRIPTION:
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NC Well Contractor Certification Number
'26.OUTI;I2:CAS7);TG formidti=cased rveUs ORL•INER'i£ii'liczTite=:.--:•:-_..
Yadkin Well Company Inc. FROM To DJAIYtTsTER TUcrslvEss MATERXAL
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Company Name <y�,' L .16:1P1PI1 R CASIl CQr OIC TLTBfii euecmal closed Iou = :- _. :
2.Well Construction Permit#: ,(I`-' . _ FROM I To DI&WM ,R� TSICIGNEss .MATERI&L
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc) ft ft• �!, y '°' S�f7`.� ' �(G
3.Well Use(check well use): ft. ft
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'17:SCREEN'*.7VaterSupply`JPell:
FROM TO -..DIAMETER 3LOTSIZB THTCENE55 MATERIAL
( Agricultural nMunicip0Public OJ 0 r. ff. in
Geothermal(Heating/Cooling Supply) 'Wesidential Water Supply(single) ft. ft
industrial/Commercial K3Residential Water Supply(shared) :- : ,gyp►
Irii OIl FROM TO MATERTAL EIKPLAMTENrASMOD&AMOTJItT 0
Non-Water Supply Well: 6ft ft
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Monitoring Recovery L ft %
Injection VVelt h-S`Utr tl
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Aquif-Recharge [�GroundwaterRemediation
A infer Storage and Recovery S Barrier FROM
S�PII7/CR'AO PP_'CL WAif T Ii AL
_ q g eIy ©f ahmty FROM TO M.ATERIAT. 'EMPLACh'MEN'I'METHOD ..
Aquifer Test 0Stormwater Drainage ft ft
I-Experimental Technology OSubsidence Control ft ft
[Geothermal(Closed Loop) nTracer 20:DRIL.LW1GL0QG tta&.-,Wai5ona2sheetsifneeess''
C Geothermal(Heating/Cooling Retum.) 00ther(explain under#21 Remarks) FRoM To DESCRIPTION earur hardness,sail/rockgrain s¢e,etc
g/ ft. 1 •ft t I �-• Shur, 1
4.Date Weil(s)Completed: 4J�y 4✓ Well D# /fir z Q 3,S—P , ft' jy R' v./ .::Z ke
5a.WellLocation: )?hone number:33 `7(-5k is ft tt
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Facility/Owne'ViTame Facility ID#{if applicable) ft. ft
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Physical Address,City,and Zip rt. ft
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County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees: ij,G(1"GE C' f�':CS51f1f]
(ifwell field,one lat/long is su$'icient) {" 22.Certification v If J ••
6.Is(are)the well(s)dermanent or 01emporary Sig❑ ofCerdfi We1lContractor Date
�!' By r gnitrg 1hts f ra,1 hereby cert�th ]at the WI(s,)was(ii+ere)contracted in accardance
7.Is this a repair to an emdsting well: nYes or I�!Pro with 15ANCAC 02C.0100 or 15A 1YCAC 02C X200 Well Construction Standards and that a
Jthis is a repair,fit!out knox n we11 construction information mad explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofihisfanm
23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled; i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10�1-—. (ft) 24a. For All Wells: Submit this:form vrithin 30 days of completion of well
For multiple wells list all depths ifdrfferem(example�and2�,7a 100� construction to the foLl owing.
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10.Static water level below top of casing: 3 (ft.) !Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" _ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit.Off •0I S 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12,Well construction method: A fir' Pdxn i L40 construction to the following.
(ie.anger,rotary,cable,di-rtp-b.etc-)' / i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm)�� Method of test: (.T 1.'�' 24c.For Water Supply&Iniection Wells: Io addition to sending the Than to
/�. the address(es) above, also submit`one copy of this form within 30 days of
Gwrs13b.Disinfection type' HTH Amount- `7• mpiet'on of well construction to the county health department of the county
where constructed_
FonnGW-1 h North Carolina Detm
gparentofEuviroumen�taall Quality
^-�Division ofWaterResources ! Revised 2-22016
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