GW1-2021-06286_Well Construction - GW1_20210915

Well Contractor Name - S�N`d rBC•il I TO nZSi`Ti.•it
63ft. 6S t. Cie IVI
5311- ft14to
NC Well Contractor Certification Number gV1
15.OUTER CASIN for multi-case ells OR LINER(if a plicable
YADKIN WELL COMPANY,INC.
FROM I TO DIATER THICL(IV1;Ss TF.RTAi•
ft. ft. in
Company Name
16.O NEER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �`I' w'�� �t�i� FROM To DLAMETER THILIO ss MAT�+1unL
List all applicable well construction pvmits(i.e.UIC,County,Slate,Yatiance,Etc. -
l ft ft. in. 5� Y
3.Well Use(chests well use); ft• ft. in.
17.SCF,Ei 1
Water Supply Well: FFOr.i TO E.1 ELO i SIZE Te E-:1t_Ss t:1.:iLPi
Agricultural ❑Municipal/Public ft. ft,
(❑Geothemial(Heating/Cooliag Supply) ❑Residential Water Supply(single) it in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) ±9.GROUT
❑Irrigation ❑Wells>100,000 GPD rP.om To lk mATERI?L EMPLACEARNT Nri3OD r PJrIOUNT
Non-Water Supply Well: ® I'' ft'
❑1\10nitoiing ❑Rtcovery rt ft. 'f!I'G
Injection Well: / iY. �ird,z ��/ M
re
❑Aquifer Recharge ❑Groundwater Remediation 19.€i.aJIDIGRAI L PACK(it applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier -r?-onl TO MATr.1UAL CKPLACT-U.- iT nMMMD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if nemssa •)
❑Geothermal(ITeating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrach type, -n she,eta
® ft. ft.
4.Date Well(s)Completed:?- t-oA Well ID# Atl V ` re 00 ft' Gj 0 ft pF1 /C� 6/Ou✓�l
Sa.Well Location: Phone # ',j 9 it, It
Facility/Owner Name Facility ID#(if applicable) 0 ft G /��t�•' llt. �s;,1 C
5'5V SG✓i h� lK� �r,��4 ft ft. -
Physical Address,City,and Zip w ft ft
6X 1('k w ba -7/. 21.RRMARKC /
County Parcel Identification No.(PIN) � t e L ed r e �+ L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifweU field,me lat/long is sufficient) 22.Certification:
33' q(;, ''7-,1 N �J 1�� �Z ll W
6.Is(are)the well(s): 01termanent or ❑Temporary Sigaatrue of Certified Well Contractor Date
By signing thisform,I hereby certify that the wefts)was 1 vere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o1q0 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out brown well construction information and explain the nature of the of this record has been provided to the well owner.
repair corder 921 remarks section or 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 W 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 TI STRUCONS
h
9.Total well depth below land surface: Vr�� (ft) Submit this GW-1 within 30 days f well completion per the following:
For multiple wells list all depths ifdifjerent(example-3®200'and 1(a}I00) ys o p p g'
` 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R) Formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level it above casing,use"+" c e
f Borehole diameter: �n-(in.) Bit Off: J I J 24b.For Injection Wells:Copy to DWR,Underground Injection Control (rUC)
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
1 13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
� r t� �
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: 7- Ov-Z i
p (/ t
Q� r VISITED BY: 1
For GW-1 r North Carolina Department of Environmental Quality-Division of Water Resources 1 V a A Revised 6-6i 2018