GW1-2021-00974_Well Construction - GW1_20210415

For Internal Use Only:
--mad.i.W�efl,Coj actor'hnfo,, --.*oq:
'fro 14.WATER?,GIVES
M Name FROM TO ft. DESCRIPTION
I ION
79
7
3 o3.6 4 ,FCF
If I It. 114 ft.
NC Well Contractor Certification Number Is.OUTER CASING(for multi-cased wells) RLINER(ifapplicible)
YADKIN WELL COMPANY,INC. FROTY1 I TO DIAMETER OFTHICKNESS IVIATrRIAL
I -loop
Company Name r15r_8Sf,!ngUNil _176ANNER CASING ORT ING(geotherma closed
2.Well Construction Permit ft: 3 FROM TO DIAMETER J,,TEUCICNESS RATEML
List a//applicable well constructionlicin,its(i.e.UIC,Cortno�SYRd,Trarta=C,etc.) 41 ,. 16 e !Y*: in. ISX-.2 I 'PVC
3.Well Use(check well-use): ft. ft. I in.
Water Supply Well: 17.SCREENPRO41 TO DIAMETER j SLOTSIZE THICKJ4ESS . MATERLP.L
OAgricultural oMunicipaYPublic .11. ft.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single)
olndustrial/CommerCial oResidential Water Supply(shared) 13.GROUT
Olrrigation_ oWells>100,000 GPD FROM TO NIATERIAL EMPLACIDYIENT METHOD&AMOUNT 0
Non-Water Supply Well: Cj ft.
C5
OMonitoring oRecovery
Injection Well: ft, ft. 0
oAquifer Recharge oGroundwater Remediation 19.SAND/GRAVEL PACK(if ae)T _
oAquifer Storage and Recovery oSalinity Barrier FROiN TO "JA EMPLACEIVIE,NT METHOD
0Aquifer Test oStormwater Drainage ft. ft.
oExper-imental Technology oSubsidence Control ft. ft.
DGeothermal(Closed Loop) oTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal Weating/Cooling Return) 00ther(explain under#21 Remarks) IFROH TO DESCRIPTION(color,hardness,soilfrock type, min size,etc-)
ft.
ft• 7 z ft-
4.Date Well(s)Completed:'3 10-.21well IDN 144LI)- 46�1 2-
ft
5a.Well Location: Phone # ?'O­ 'qq- 3c236 7-3 ft' Sli
9, K?/ J-'r ft-
5e 77
'facility JID#(if applicable) it. ft.
Facility/Owner Name P
PejAle ft. ft.
Physical Address,City,and Zip ft. ft.
51 21.REMARKS
County Parcel Identification No.(PIN) M � z
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 N S11 /0
Signature of Certified Well Contractor Date
6.Is(are)the well(s): Oermanent or OTemporary
hereby certify that J
By signing thisforin,I at the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or $No 15A AICAC 02C.0100 at-15A NCAC 02C.0200 Well Constniction 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 back of this form. 23.Site diagram or additional w ell 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
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft Submit this GW-1 within 30 daps of well completion per the following:
For multiple wells list all depths ifdifferem(example-3@200'and 2@1000 i
_r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,160 MSC,Raleigh,NC 27699-1617
If water level Is above casing.use
11.Borehole diameter: (in.) Bit Off: 6, o c.s 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC) <
Program,1636 MSC,Raleigh,NC 27699-1636
12.M AIR ROTARYiell 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 27699-1611
13a.Yield(gpm) I Method of test: 6 0
70%HTH oz DATE SITE VISITED:
13b.Disinfection type:- Amount:
VISITED BY-
-h rprolina Department of Environmental Quality-Division of Water Resources
11 44
X