GW1-2021-05579_Well Construction - GW1_20211013

F E 0 P,T TO DZSCEIDT C-P
Well Contractor Name q0ft. �211
3oS(o A T ft. ft.
NC Well Contractor Certification Number ( TV) )
0�0� •-qJZ 15.OUTER CASING for Tulti-cased wells) LINER if 2 licable PC- FROM nun THICIM Ss MATERIAL
YADKIN WELL COMPANY,INC. vo^ S5
Company Name ya Jk;0. 3 7f,, 9'519 7 416'r
16.INNER CASING OR TUBING(6othermalcTosed-loop)
2.Well Construction Permit#:Ws,^P 2a21, FROM I TO DLUVIETER THIaM SS MATiLRIAL
List all applicable well construction permits rje-WC,County,State,Variance,etc.) + I ft. 1/+ in. low
3.Well Use(check VeilV-se): ft. in.
17.SCRI-:ZN
Water supply,%rell: rp
..Orll TO DLU-IETER SLOT SIZE THICTCiESS NIATEMAL
DAgricultural DMunicipal/Public ft. 0,.*, ft.
DGeothemial(Heating/Cooling Supply) Residential Water Supply(single) >00 0' in.
01ndustrial./Conimercial DResidential Water Supply(shared) 13.GROUT
DIrrigation OWells>100,000 GPD MON TO PILATERIAL EMPLACETIENT P.0THOD rl A1,10UPIT
Non-Water Supply Well: D tt. -3 ft. 81'1+o OtNL 'is 6re-v*r 3
0monitoring ORecovery
frijection Well: I N
DAquifer Recharge Mroundwater Remediation 19.SAIIEDIGRAICI,L PAC, tit applicable)
DAquifer Storage and Recovery oSatinity Barrier FROM TO rrmTEM I, ED,,JPLAC-Lir.fMT&M-IHOD
OAquifer Test OStormwater Drainage
DExperimental Technology OSubsidence Control ft. "'00,ft.
DGeothermal(Closed Loop) OTracer 20.DRELLING LOG(attach additional sheets if necessary)
DGeothennal(ffeating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(cdar,hardness,soittrock typN Krain size,etc)
4.Date Well(s)Completed:' IS Well ED# /S U I
-AAQ- RE /50 ft- 170 ft- J14.4 6^zn),&
5a.Well Location: Phone #,Z,;V,. 7S 3.7 ­7A?J2'7 /70 ft' 3 70 f" SW4
A&e,x goac 1. . 370 ft 70 7- ft AJIRW
Facility/Owner e Facility D)#(if applicable)
I P ft. ft.
Physical Address,City,add Zip ft. ft
YCI 4 k i r\ 1 21.REMARKS
County Parcel Identification No.(PIN) 02
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
T C'o i J_ 7 Y-/ N 5b' 37, 9'9-3 W
6.1s(are)the wc]l(s): �e anent or OTemporary gnature Of Certified Well Contractor Date
By signing thisform,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or Alko 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction 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 well details:
8.For Geoprobe/D.PT 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 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: 70 2- (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ff&fferent(imomple-3@200'and 2@100�
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), J
lfwarer level is above coxing,use Information Processing Unit 1617 i MSC,Raleigh,NC 27699-1617
1 .11 T
11.Borehole diametei: (in-) Bit Off:X'530 24b.For Infection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-163 6
12.Well construction method: AIR ROTARY 24c.For Water Supply and Opeii-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct pusk etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingiover 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)- 7 Method of test: rJX fit Permit Program,1611 MSC,Raleigh,NC 27699-1611
70%HTH Amount: 0z DATE SITE VISITED:
13b.Disinfection type: VISITED BY:
Form GW-1 North Carolina Ddift
pt of Environmental Quality-Division of Water Resourceswised 6-6-2018