GW1-2021-00971_Well Construction - GW1_20210415

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NC Well Contractor Certification Number Un11 15.OUTER CARING multi-cased ' Is)OR UTTER(if applicable
Inf'arr(;atlon prooez,ing FROM To. DIANE] TffiCICNESS P IATERIAL
YADKIN WELL COMPAI\IY,IhIC- rVAIR , nAN
ft. ft. in.
Company Name .1 L 3.3r,- L&1- - T 3 '- C% 16.INNER CASING OR TUBING(geother©J closed-loop)
J FROM TO DIAPIETER TFIICICKESS N.I�TERL�L
2.Well.Construction Permit#: fr. d ft.
List all applicable well construction perurils(i-e.UIC,Coanyy,Stale, 1 ariance,etc.) �� O-7 &p, Z� r /�
_.10101 Use{e`i=A'i,,,,e l!,'se):
SC'TEt 1
;-rnia��'a�raiy�'•,';'1. - ,cl - -- Al i.'•::r"_:.�
H�,ruIwral ❑Pdittn!c;pal/Pubhr.. I sr. I I I�
❑Geotheh.nal(H a.iing/Cooting Sup iy) ❑Resident!al Water Supply(single) ;;-
❑Industria!/Commercial ❑Residential Water Supply(shared) 1L GR.ra1iT
❑Irrigation ❑Wells> 100,000GPD I
TO FL-NTZPtAL Eh'lLA.CEP.1EiITPilETL0Dr;-,ri Sri!'
7w❑Monitoring ❑Recovery {t• Ida- 't e'
1! Well:
snac':60 Well: f# ft.
❑�yuifer Recharge ❑Groundhvater Remediation ,J
19.SA!Is/GRA LI r'r�Cli(t:r a pltcable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO I rr 1TERna_-L EIhIFLACEPAMT METROD
❑Aquifer Test ❑Stormwater Drainage ft. ft. I i +�
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.1DRILLMG LOG(attach additional sbeets if necessary)
FROM TO DESCRIPTION(color,hardness,saitIrcck pc,grain size,etc.)
❑Geothermal(Heating/Cooling R^e�tu2m) ❑Other(explain under#21 Remarks) ® f.. 7-7 ft.
4.Date Well(s)Completed:J OJ Well ID# AA-0 3 70 -7-7 ft. 3�')0. zvie,/ v e „• �
ft. ft. ro
Sa.Well Location: Phone # 1
i
ft. ft.
Facility/Owner Name Facility ID#(of applicable)
i �s��Gl, � t31 '4t�ff�t� is fi ft. ft.
Physical Address,City,and Zip
Ai L 21.REjAMRICS t
County Parcel Identification No.(PIN) Q
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) G / t 22.Certification'
6.Is(are)the well(s): Of�rmanent or ❑Temporary ture ofC ed Well Contractor Date X�
By signing thisfonn,1hereby certi5#that the wall(s)was(were)constructed in accordance with r
7.Is this a repair to an existing well: ❑Yes or BNo I5A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Constnrction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ojthis retard has been provided to the well owner.
repair-under 921 remarks section or an One back ojthis 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 pageito provide additional well construction info
construction,only 1 G W 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: -1 . 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��� (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if differ-ent(exannple-3 rt 200'and 2Q100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �® (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use
Bit Off: 6 a t°V,5d 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(IUC)
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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) If Method of test: t�
70%HTH +gyp OZ DATE SITE VISITED: ZZ-2
13b.Disinfection type: Amount: N.
VISITED BY:
Form GW-1 Nord?Carolina Department of Environmental Quality-Division of Water Resources F Revised 6-6-2018
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