GW1-2021-05462_Well Construction - GW1_20210615

We1lConhactorName '"��'�'°" Fr•OCt TO n`SCI;u•TI^il
4(46- Jl
A ;� � -0 2�Z ft. % I ,
NC Well Contractor Certification Number
lll 15.OUTER CASING for multi cased dells OR LINER it a plicable
YADKIN WELL COMPANY,INC. ppOC"�' BRonz To DLIn�TCR THIQOVGS5 TERIAL
e'sG41T,3uC� ft. ft. ' ',in.
°Company Name V U
- l �/p 16.INNER CASING OR TUBING(' othermal dosed-loon)
1.Well Construction Permit#:�R�l��.�1 d O G 7� FROM TO DIAMTrR THIC{M,SS MAIRRML
List all applicable well construction permits(Le.UIC,County,State-Pare,etc.) �i fL L Q fL in. s m a t P-V
3.Well Use(cheep well use): ft. ft. in.
Water Supply Wl'ell 17.SCRL i l
t.1?Ord TO D1A.P.--:T2AI SLOT SIZE I TETiCIRRESS I P9nTy:RLr -.
Agricultural �, G ❑Municipal/Public ft, ft. irt.
!❑Geothemial(HeatineCooliug Supply) ❑Residential Water Supply(single) it. I ft.
❑lndustrial/Comnercial ❑Residential Water Supply(shared) L::GROUT \
❑Irrigation ❑Wells>100,000 GPD FROM TO PIAT>"J"L EMPLACEI MMNT METHOD c;AIAOUiNT
Non-Water Supply Well: ft. / ft. 140le. pl. 0 Jw L S
❑Monitoring ❑Recovery �, ft ft. t C
Iniection Well: , ft. o>
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.9A1ICMPA1'LP L PACIs of ap.licable)
FROM TO MAMMAL ED., LACrs.MiD—ILTEOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft, fL .. s
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal Meating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION! color,bardaess,soillrodc typZ grain sae,ei¢
ft. G3 fL ®,1
4.Date Well(s)Completed:S- ?1 J i Well EW. — 63 IL ? ft eh n f -
Sa.WellLocation: Phone
ft: ft.
Facility/Owner =r Fa 16AQff applicable) ft ft
ft ft.
Fhysi.Address,City,and Zip ft. ft
! ll.RRMARTCS
County i Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (V�
(ifwell field,one lat/long is sufficient) 22.CertiScation:
N w S 0t
6.Is(are)the well(s): [ Permanent or ❑Temporary Sign of Cettilled well Contractor i Date
- •By signing this form,l hereby cen%yy that the wells)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(mown well construction information and e*laln the nature of the of this record has been provided to the well owner. ..A
repair render#21 remarks section or on the back ofiNsform. 23.Site diagram or additional well details: !
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sameF You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells`; (add'See Ovice in Remarks Box).You may also attach additional pages if necessary_ '
drilled: 24.SUBIVIITTAL INSTRUCTIONS
i
9.Total well depth below land surface.'.,' (ft)
For multiple wells list all depths fdiffesent(esample-9©200'and 2@100D Submit this GW-1 within 30 days,of well completion per the following: �.
3o f 24a. For All Wells: Original form;to Division of Water Resources (DWR),
10.Static water level below top of casing: '. (t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above ca#ng,use"4- (_
(O (in.)
Bit Off: to •0$ 24b.For Injection Wells:Copy
11.Borehole diameter': to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well constructionmethod: 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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1"000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 1 Method of test: p Pennit Program,1611 MSC,Raleigh,NC 27699-1611 1
70%HTH J OZ DATE SITE VISITED: +1
13b.Disinfection type: Amount
VISITED BY:
Form GR'_1 u•; .. rth"Carolina Department of Envaonraental Quality-Division of Water Resources' Revised 6-6-2015