GW1-2021-01830_Well Construction - GW1_20210503

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20
Well Contractor Naine
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1 y 51 MCC 9 0/E ft. 14/0 ft- c PM -
NC Well Contractor Certification Number (1S IS.OUTER CASING for multi-eased wells OR LIIE R(if applicable)
YADKIN WELL COMPANY,INC. MA`( X " FROM I TO DIPS•IETry THICLNEss 11_,M1.IAI, ^
it. I in.
Company Name un11
processing 16.I BIER CASIG OR TUBUIC(t eothertaa[closed-loop)
2.Well Construction Permit#: `' �A€`Alp sedon FROM TO DIAMETER TFIICs4VrSs nv€TZKLAI. `
List all applicable well construction permits(i.e.UIC,County,State,iZariance,etc) ft• I a `t• 1i llk f 1° $OR a7 I. P v c
ff. it.3.C13 Use(checht rve 11 use):
•.5�:'�F-ei'�tR;�t3iy 'el": OH '� 'ro IANETi:, CLO T SK"E T-i7LC?71_S3
�a
❑Agricultural ❑Municipal/Public it.
❑Geothermal(Heating/Cooling Supply) fi%Lesidential Water Supply(single)
❑Industrial/Conm?erciai ❑Residential Water Supply(shared) l i.GE:^darn
❑Irrigation ❑Wells>lK000GPD --;ti i:':,;E Et-?AC=ir iiTr<rTti01--A!,!0 HT
Non-Water Supply Frl'e13: D i`` 3 14o(e P P00peJ 3 W S
❑Monitoring — ❑Recovery 3 ft• 3 O Qw ck G ro-4 Pu d L� l�L a s.
Itiajection Well: ft. £t.
❑A uifer Recharge ❑Groundwater Remediation
q i;'.uA1NI•Jr',o�r\,rs✓L o-A Cii(if a7riicabtFl
❑Aquifer Storage and Recovery ❑Salinity Barrier FROP-1 TO A-UTER—Iar! r-IF LA CEP. VTNIET0uD
❑Aquifer Test ❑Stomiwater Drainage
❑Experimental Technology ❑Subsidence Control tr
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FRONI TO DESCRIPTION color,hardness,soiltrock e, rain size,etc.
❑Geothermal(lieating/Cooling Return) ❑Other(explain under#21 Remarks)
/ ft. /d J ft. G 'I :.
4.Date Well(s)Completed: 11 Well IHD# Al 0-mo//t`�eA l0 s ft- 4 a a ft` G rownf e
ft. ft.
5a.Well Location: Phone #!,® ����•�189
ft. ft.
�k,'Y k /-'14 i tl.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Lei h 4 vG e&, Re'd f t Ta f f ft. ft.
Physical Address,Cityrlad Zip V ft. ft.
/f sl 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
5'4rG 9 N 5/ 3Ss 5 G 4 G W a 3131131
6.Is(are)the well(s): APermanent or ❑Temporary
Signal of, ertified Well Contractor Date
By signing thisforn%I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )IAINo 15A NCAC 02C l0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the oflhis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/IDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 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: t_�1'1 (ft') Submit this GW-1 within 30 days of well completion per the following:
Por multiple wells list all depths ifdifferent(example-3@200'and 2@100')
24a. For All Wells: Originallform to Division of Water Resources (DWR),
10.Static water level below top of casing: O (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: �e (in,) Bit Off: •l/V 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop 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 WELLS ONLY: 24d.For Water Wells producing over 100,000 GPID:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC,27699-1611
13a.Yield(gpm) S Method of test: 01
70%HTH � L oz DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 North Carolina Deparhnent of Environmental Quality-Division of Water Resources Revised 6-6-2018
4C;