GW1-2021-01972_Well Construction - GW1_20210503

-----------------
Intern al Ust On i
N W6
FROM TO I DESCARPTiON
Well Contractor Name 79 " -7q `4 1 3S18- 3S' _q a
30 U /A ;70 ft. 2-71 "4 1 :1
NC Well Contractor Certification Number 15.OUTER CASPTG(for T!11�D Zed wells P!LLINER k1f 21POliCable)
'Tr
YADKIN WELL COMPANY,INC. FROM TO R THI I MATERIAL 40-1
Company Name TV
16.INNER CASUNG OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3 FROM TO DIAINETER THICHNESS MATERIAL
List all applicable well construction permits(ke.UIC,Cozmi)�State,Variance,etc) 4- 1 J-9 6 VIL " SAK-a?L
3.Well Use(check well use): fr. ft. in.
7.
Water Supply Well: 1 SC1'3 EPI.ROT-1i TO D1_1PJET2P.! STLOTSIZE TMICNiESS P'1ATE-P.L'%L
OAgricultural CMunicipaVPublic ft. ft.
DGeothermal(Heating/Cooling Supply) residential Water Supply(single)
ft. 1401-
01ndustrial/Commercial DResidential Water Supply(shared) 13.GROUT
DIrrigation DWells>100,000 GPD FROM TO RLATERML EMPLACEDHUIT ATETHOD_2,AT-.-1O!JP1T
Non-Water Supply Well:
DMonitoring DRecovery 3 ft- ft- "A
Injection Well: , ft. ft. !!
OAquifer Recharge OGroundwater Remediation
19.SrViDIGRAVE L PACK(if applicable)
DAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL UIPLACEMEENT METHOD
OAquifer Test OStormwater Drainage
DExperimental Technology OSubsidence Control ftDGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if oecessary)
DGeothermal(14eating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ft TO it. DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
0 - 7 -7,1,,
4.Date Well(s)Completed: 11-q Well ED# A46 - 7 fL -9 ft.�r vt � S.-,r-fL Ad r
5a.Well Location: IJS" 3C2- ' yn�l Y
Phone # ft. fL
90 k1'A wit flack_
Facility/Owner Name Facility EID#(if applicable) ft• ft.
Physical Address,City,and Zip fL fL
21.REMARKS LAAY Y
County Parcel Identification No.(PIN)
Pro
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ton
(if well field,one latAong is sufficient) 22.Certification:
N W
6.Is(are)the well(s): 01?ermanent or OTemporary Si cure of Certified Well Contractor Date
By signing this form,1herehy cert)ry that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 8No 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 construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the bark of this form. 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 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 IN (51C
9.Total well depth below land surface: 3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100')
,f I A 24a. For All Wells: Original forn 1 to Division of Water Resources (DWR),
10.Static water level below top of casing: 7U _(ft.) Information Processing Unit 1617 M I SC Raleigh,NC27699-1617 ai
lfwater level is above casing,use"+
11.Borehole diameter: ID (in.) Bit Off: I; 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUQ
I
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-L I oop 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 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: r& ea Perm FtP-rogram,1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
VISITED BY:
Form GW-I North C olina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 I'll
IfI
AA c44p%&"&-t ho r a -.- /?C,it i I