GW1-2021-07093_Well Construction - GW1_20210915

Well Contractor e iP;Oi.I TO Li�t_�TQi!
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas!;wells OR LF1d-R if applim 1
YADKIN WELL COMPANY,INC. FROM TO DL AM-ER TBICc[OfEss TERIAI.
ft. ft
Company Name S(A V yr Vo I, f3 2-5- 16.IPINEIt CASING OR T[lRWG(geothermal closed-too
2.Wetl Construction Permit#: W( ZO-%60 q FROM TO DIa mi TER I TI3rt3Q4Is'ss MATEML
List all applicable well construction permits(ee-WC.Cmmty,State,Variance,etc IL R' ,1�11e. J 2-a r-L
3.Well Use(cheat well uze): ft. ft in.
17.Water Supply Well: M
i•e'Ordi l
•4 TO DL•_ta_T:;R SLOTSiZE TxTrtr41ES0 i••1=:TiPi'•.L
❑Agricultural DMunicipal/Public ft. ft in. -
❑Geothermal(Heating/Cooliug Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 6F.OU a
❑Irrigation ❑Wells>100,000 GPD pnord TO MAMMA,- EMPL ACEr.ENT Ire T gOD c a1:iOUN T `
Non-Water Suppl3r Well: D t' � ft.
1 u irk
❑Monitorin ❑Recomre ft ft
Fnjection Well: � � � p�.,S/p � •� ��
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation __...
19.SAPID/GRAVE L PACK(if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FEOD-1 TO MATrarer. Crtpr.aMr:e-rt••ri METE=
❑Aquifer Test ❑Stormwater Drainage R• fr-
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessa )
❑Geothermal(Ileating/Coolmg Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sail/roetc a o scq eta
e� ` ® ft- .13
4.Date Well(s)Completed: 0 "S' a I Well ID#��// I'0 3'�
- Z-) ;L R o�f3CssfL P�,��rt-� rat•'i•r
Sa.Well Location:: / Phone #J&1, 7 - Z ft. ft
Tanztey Mzl-h-i( ft fr.
Facility/Owner Name/ F-acilityM#(ifapplicable) IL ft.
77 ZZ 1-- �16 Y�f iAi Id' A-1/'I.0c ft ft
Physical Address,Cfij,arid Zip M ft
zi.REMARr�s �
County J Panel Identification No.ON) J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/lo is sufficient \u11 i S s r rOn
( rr8 ) 22.Certification: `„y(Oli;1'�'\`)�C,n,l•
?' G 63 N 80" 29.
6.Ls(are)the well(s): ❑Permanent or ❑Temporary Jij5dine of Cent d Well Contractor Date
Qysig?dng thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15ANCAC 02C.0100 or 15ANCAC 62C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fdl out brown 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 well details: 6•
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 l
construction,only 1 GW--1 is needed. Indicate TOTAL NUMBER of wells (add'See Oven'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMTITAL INSTRUCITONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following: N
For multiple wells list all depths if different(example-3©200'and 2Qa 1000
10.Static water level below top of casing: 7L�• (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwarer level is above casing,use"+/" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter (L (in.) Bit Off: �o�Q� 24b.For Injection Wells:Copy ito 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
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY' 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCU
AQ- Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)�0 Method of test: �� /CA
13b.Disinfection type: 70%HTH Amonnt: OZ DATE SITE VISIITTEDD:y�C 1/ 2 Q 1
VISITED BY: KJ Vfs I a
Im 1 J
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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