GW1-2021-00972_Well Construction - GW1_20210415

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REAL,'J Ii'(�jlT�'i�t S11` r� {I 1 l li< !I /`J-II'.= For Internal US(--0111y: i
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11.�5'el1 o�sraetor dlaorrraSion: __
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Well Contractor Name iLnl ft. s ft. DESCRIPrIa
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2021 6' fr. ft. ' dO
NC Well Contractor Certification Number APR 15.OUTER CASING for T!LW-cased s)OR LINER(if ap licable
YADKIN WELL COMPANY,INC. Unit FROYI TO DL>P4ETER rHICKNESS le
P.SSIl1C� ft. ft. in.
Company Name secttOn
/�DWR 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:_, ��t FROM TO /DIAMETER THICKNESS MATERIAL
Gist all applicable well constrziction permits(i.e.U1C,E°onnly,State,Parionce,etc) / ft. 5- ft. V 6 X0 in.
f q✓ S7,Fe-e nli
3.Well Use(ciaeclt well use): fr. it. in. li
17.SCREEN l
Watet•Supply Well: rRo'M TO DLAMIL'TER I sLOTSIZE .j TFIICK;•1Ess MATEIIIAL
gricultural ❑Municipal/Public It, ft. it3,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. i .
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
❑Irrigation ❑Wells>100,000 GPD rROr:1 TO MATERIAL EMPLACO IENT METHOD&AMOUNT
Non-Wale; Su:gQly Well: it. 3 ft. 1 WBs'Tei cll ) j d CA C�
❑Monitoring ❑Recovery ft. 30 .��
Injection Wen:
ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEL PAC ii(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROA1 TO MATERIAL EN4PLACENIENT l•IETIIOD
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. r
� viz �
4.Date Well(s)Completed:�� Well ID# tt. ft. th-elf
5a.Well Location: Phone # fee' y. 93�C9 -e'olr yr
Facility/Owner Name Facility ID#(if applicable)
�QC w y 9'9/ 30 7 9 -
Physical Address,6ity,and Zip
5 21.RENIARKS
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:
3G �3.9��1 N '3 �;2 � w
6.is(are)the well(s):loermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fo i,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes oY. 6so 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oul known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this fornn.
• 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: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1
For multiple wells list all depths ifderent(example-3Q200'and 2 rer lo0q Submit this GW-1 within 30 days-of well completion per the following:
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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"+" /
11.Borehole diameter: Bit Off: n �5 24b.For Injection 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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!over 100600 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,,NC 27699-1611
13a.Yield(gpm)� Ii'y)� Method of test: G'� V jI
13b.Disinfection type:
70%HTH Amount: tC� OZ DATE SITE VISITED: 3 ! O `N r
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Deve_(c. VISITED BY:
"--,•r"•-nlina rlenn tment of Fnvirnnmentnl r)nality-nivicinn of Water Resnurces