GW1-2021-04311_Well Construction - GW1_20210415

,77E C101",TSTRUC T101V RE,NCO (GW For Internal Use Only:
1.Well Contractor information:
old T rItiW 3 d) WA 1=4:WATER ZONES
Wel Contractor Name .FROM TO DESCRIPTION
lip -I
9 ft. ft
,.� aC ft. 3 ft
NC Well Contractor Certification Number 15 OUTER CASTING for ritulh cased wells OR LAVER if a hcable
YADKIN WELL COMPANY,INC. FROM , _TO IMQ DETER THICKNESS MATCRiAL
JJ 11 2021
Company Name b/�j� t t.CilrfOC"S'';B�UBI 16.TiVNERCASINGORTUBING eothermal.closedloo ) V`— "`-
2.Well Construction Permit#: L��/ ew to ..,, tea!1:OC1 FRotvt To DIAMETER THICKNESS 14IATCRiAL
List all applicable well conshuction permits(i.e.UIC,County,Stat P.lY riance,etc.) ft. (� ft. I`, in. Any U s°
3.Well Use(check well use): ft. ft. L� is UK l•
Water Supply Well: 17.SCREEN -
PROM TO DL4i1LTER: SLOT SIZE THICKNESS MA 151,
OAgricultural oMunicipaUPublic
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single)
❑IndustriaVCommercial ❑Residential Water Supply(shared) 1✓I.GROFJ T u
❑Irrigation ❑Wells>100,000 GPD - FROM TO MATERIAL EMFLACE[YM-NTMETHOD&AMOUNT.
Non-Water Supply Well: f±. 3 ft. /_ "t
❑Monitoring ❑Recovery ft. 3T ft. u _/1PZ
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(ifi 'licable); '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEIYIENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft if
❑Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) ❑Tracer 20.,DRILLING LOG attach additional sheets'ifueceisa"
.FROM TO DESCWTION color,hardness,.soiVrock ce in size,etc
❑Geothermal(Ifeating(Cooling Return) ❑Other(explain under#21 Remarks) ft ft S
4.Date Well(s)Completed: 3 —2—21 Well ID# 0- 31Y sj ft- 3 1 ft S'�LQ ( ire
�y
5a.Well Location:
Phone # g-Ass-�/ 3Ift 227— ft ,T
AVz7/1 J/I aCa ft ft.
Facility/jwner Name y Facility ID#(if applicable) ft. ft.
Physical/Address,CCiety,and Zip ft' ft'
iV r/t � 21.REMARKS _
County Parcel Identification No.(PIN) ``L /a `r Lul 2 '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: T I I r
(if well field,one lattlonn�g is sufficient) et 22.Certification:
3G �-S. 9ssd N W Se
6.Is(are)the well(s): YPermanent or ❑Temporary Signature of Certified Well Contractor Date
`' By signing thisfoini,I hereby ceit ify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �Vo 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 a/d explain the nature of the of this record has beenprovided 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/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 I GW-1,is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I.? / (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3 a 00'and 2@100�
24a. For All Wells: Original form to Division of Water Resources,(DWR),
10.Static water level below top of casing: B (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use ;
11.Borehole diameter: (in.) Bit Off: 6� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY c
24c.For Water Supply and Open-Loop GeothermalrRelurn Wells:Copy to the (�
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of thrdoi my where installed
FOR WATER SUPPLY WELLS ONLY: over 100,000 GPD:Copy to'DWR,CCPCUA
24d.,For Water producing,
NC 27699-1611
Permit Program,1611 MSC,Ralei h,
13a.Yield(gpm) � Method of test: �.��
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: ` ('C
"v76 �"Nl VISITED BY: 1�1�, I �✓�` `INJL�
Form GW-I North Carolina Department of Environmental Quality--D�of Water Resources Revised 6-6-0s188 [`.(/