GW1-2021-01852_Well Construction - GW1_20210503

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Well Contractor N�ame TO I DZ3C:t9VDi1
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cas&&'wells)OR LINE applTO DIPIIETER THICKNESS icable
YADKIN WELL COMPANY,INC. -F-R-011-11 T7
Company Name ft. ft. in.
16.MNER CASING OR TUBING(genthermal closed-loop)
2.Well Construction Permit#: Oen,)S_ rRom To DiArvm= THICIMSS MATERIAL
List all applicable well construction permits(Le.UIC,County,State, Variance,etc.) ft. 9�x_0114,/�,S'in. Y4,
3.Well Use,(chec?t well use): ft. I ft. in.
Water Supply Well: 17.SCPEE N
FROP.11 TO DIWILTER SLOT-STEE TO-CPaIESS H-ATEMiAL
oAgricultural OMunicipaUPublic
DGeothermal(Heating/Cooling Supply) Xesidential Water Supply(single) ft. in.
Ohidustrial/Conimercial OResidential Water Supply(shared) I&GROUT
01rrigation OWells>100,000 GPD FRONT _ TO (,LATEPLTA_L EP1?Li!C:F.C1,VTP.,M-TEODa,Ai,107WIT
Non-Water Supply Weill: fl. ft' Rol-,-c-
DMonitoring DRecovery ?,.,
Injection Well: ft.
DAquifer Recharge EIGroundwater Remediation 19.SADIDIGRAVEL Pp,-!C (if appli coble)
DAquifer Storage and Recovery OSalinity Barrier FROP11 CTO I MATERIAL EMPLA CELIFENT ME THOD
[]Aquifer Test OStorinwater Drainage ft ft.
DExperimental Technology OSubsidence Control ft. ft
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets ifnecessary)
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
f2 ft ft.
4.Date Well(s)Completed: 1-1-11-11 ol ft. /4)- eft. /r7
;
5a.Well Location: Phone # j??,/+w/J Q
lIC14 A z/
Facility/Owner Name Facility BD#(if applicable) ft. ft.
ft. ft.
VE D
Physical Address,City,and Zip ft. ft.
e, AI 21.REMARKS MY Y R 711?1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: P.-P R-40P
(if well field,one lattlong is sufficient)
22.Certification:
35 2 C. N IF 6 49;3 4 W
Ar�z.&& 1113 0-11
6.Is(are)the well(s): Atermanent or OTemporary !jjwr=of(Wed Well Contractor Date
By signing this form,
I hereby certify that-the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 01.Ves or An 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construclion information bnd explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthisform.
23.Site diagram or additional well 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 NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft*) Submit this GW-1 within 3.0 days of well completion per the following:
For multiple wells list all depths If different(example-3@200'and 2@1001
24a. For All Wells: Original form 4o Division of Water Resources (DWR),
10.Static water level below top of casing: 30 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I I
Bit Off: co 24b.For Injection Wells:Copy tolDWR,Underground Injection Control(IUQ
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health Method of test: A* department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I I i
24d.For Water Wells producing e 100,000 GPD:Copy to D`Wl;�CCPCUA
13a.Yield(gpm) V0
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
li
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018