GW1-2021-05297_Well Construction - GW1_20210615

Well Contractor Name �1 �,1 � � i�T:C•CI ft TO L I;�Scr.�atoll
�r.• OSS1Cea.Uill ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells)ORLD�IER(ifa plicable
YADKIN WELL COMPANY,INC. FROM To DMAD;TLR THICIQV S TERIAL
ft, ft. in.
Company Name 16.INNER CASING OR TUBING(geotherma]dosed-loop)
2.Well Construction Permit#: Y E' �4 o�V o -L'��•� FROM I To I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(ae.UIC,County,State,Variance,etc.) ft- ft. 1°
3.Well Use(check well use): ft. ft in.
17.SCR
Water Supply Well: 2 l
ri_ord TO DUPrIsTeR SLOT SIZE MCN74ESS ilLTERLAL s
❑Agricultural ❑Municipal/Public ft• ft
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft in.
111ndustrial/Conmiercial ❑Residentia)Water Supply(shared) fig•G'UUn
❑Irrigation ❑Wells>100,000GPD MON TO CtATE-PLAL rr.LnLACE-F.- NTnVrTHOID0AlrIOUNY `�'^
Non-Water Supply Well: tt, q ftNOV ?� POUCCcy I` �/
❑Monitoring,:; ❑Recovery P� ft. P
Neetioll Well: f" 19 d ft 1t 1t G 10 S�
OAgnifer Recharge ❑Groundwater Remediation
19.SA2i D/GRAi LL FACIi(if applicable)
t7AQulfer Storage and Recovery ❑Salinity Barrier r-ROPI TO MATERIAL ED., LACLP.>r�.VT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
4
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
[:]Geothermal(Ileating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DMSCRIPiTON ca[or,hardness,saiUraetc ain size`etz
ft. 0
4.Date Well(s)Completed: 3 4S 92t. Well m# AHO 521 -70 ft .343 ,
Sa.Well Location: / Phone #33 !�� )�/ ft ft
° L.4u�SOt� / d ft ft.
Facility/Owner Name i Facility lD#(if applicable) ft•
ft. ft.
393' t�M
Physical Address,City,and Zip ft. ft.
A,AV Ares.
21.RRMAR 0 y�
County Y I Parcel Identification No.(PIN) a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
P
(if well field,one lat/long is sufficient) 22.Certification:
$1N ® W
6.Is(are)the well(s): Wermanent or ❑Temporary
Si of Vertifid Well Contractor j, Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction infortnatian 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 thisform. i
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 needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: - 24.SUBMITTAL INSTRUCTIONS
•
9.Total well depth below land surface: ,1 (ft)
For multiple wells list all depths if different(example-3@200`and 2 @100 0
Submit this GW-1 within 30 days of well completion per the following:
/ ( ) 24a. For AH Wells: Original fan'u to Division of Water Resources (DWR),.
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casvrg use
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
(ie.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) ��� Method of test: al;,- / 00
7:0%HTH OZ DATE SITE VISITED: ,
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 , North Carolina Department of Envirnr:uental Quality-Division of Water Resources; Revised 6-6-2019