GW1-2021-01860_Well Construction - GW1_20210503

Well Contractor Name r hvr:1 TO sESC:Ie'TaQtI
ft' "i�70 ft. ?t° ipml l
��{I�,�. I� ft• �,7�ft. � ���
NC Well Contractor Certification Number 15.OUTER CASING(for-meld-cased w• s)O.LAEd(if sp
YADKIN WELL COMPANY,INC. FROM To DIAMETER aw=Lss tA E-1
Company Name A A rt, 16.INIC,R CASING OR T U1BDIG(geothermal closed-loop)
2.Well Construction Permit#: A t-o ^�-IL'LD D/4 C oplk�' N FROM TO DIAR3ETER THICKTIrSS PIATERIAL
List all applicable well constntction permits(i.e.UIC,Coanp;State,Pariance,etc.) 4 t't. ft. in. v e `Q 0
W�
17.5C_i,s 1,N
f,�/�/, ;•RCia � � _=i:1=-°P. -� 'LCTS 7_ � Ti1IC=31E�3 i.;:.TPr.t.=:�
❑AgisCUliLral Air r-
❑Geotlienllal(Heating/Cooling Supply) ❑RCSideltial Water Supply(single)
❑lndustriaUComniercial ❑Residential Water Supply(shared) 10.GI1„tt y
❑Irrigation ❑Wells>1.00,000GPD iROPP.? I TO r6L-T_PL-1.Ly , =_rNVII._rTNENT NET ROD a:_r.1OUHT
N"-Vilizea slip-ply'Vell: V f7. 620 f'e. Gncrc4e I 1 p�O&.1 �P
❑Monitoring 0-RecoverylOW I Q61APN nJ L40 51
yn)eciio?Well:
,�. ft.
❑Aquifer Recharge ❑Groundwater Reliediation 1-9.SAP,OWGRAVEL PACT=(if applicable)
❑Aquifer Storage and Recovery ❑Salini),Barrier . FROM TO I ISIATERL3L EQ4PLACEP:IENT NT:THOD
p ❑Aquifer Test ❑Stormwater Drainage ft. I ft. t�
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attacb addi,ional sbeets if necessary)
S 6 ❑Geot]lemial(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soivroctt type,grain size,ctc)
9 ® ft. �� ft- Soil
4,Date Well(s)Completed: 31 D 1�ad Well ID#A1i --o ig ft. qyj ft. _,� .
jr
5a.Well Location: Phone #-3.X- 7-.99i- 1J&q6 ft. ft. e G
CIL,AQy- � ft. it. /,. '1
Facility/Owner Name Facility ID#(if applicable) ft. ft. O ��Jp
ft. ft.
Physical Address,City,and Zip ft. ft. �IOLr Vpn
21.RERRICS IA
P4
County � Parcel Identification No.(PIN) ��a �`� �''t t �•D �� '� • 6I���t•�1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �'iril
(if well field,one]at/long is sufficient) 22.Certification:
36 Irl N 7q W oe �6
,�
6.Is(are)the well(s): fylPermanen4 or ❑Temporary Signatur�of Ce:' ed Well Contractor Date
// By signing this form,I hereby cert�,that the well(s)was(were)constricted in accordance with
7.Is this a repair to an existing well: Dyes or ff o 15A NCAC 02C.0100 or l5A NCAC 02C.0200 WC11 Cautr-uction Standards and that a copy
If this is a repair,fill out known well construction information and exploin the nature of die of this record has been provided to the well owner.
repair under 921 renmrks section a•on the back 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'ill Remarks Box).You may also attach additional pages if necessary.
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'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
Ifwater level is above casing,use"+"
i
11.Borehole diameter: (in.) Bit Off: 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
qq Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �® Method of test: A�°�
o � DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: � OZ J
pri t-P VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2111