GW1-2021-04229_Well Construction - GW1_20210415

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cl 1aV-G 14.IYATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. 6 30 ft. �1
NC Well Contractor Certification Number r 2021 15.OUTER CASING for multi-cased wells)OR LIVER i#ap licable
YADKIN WELL COMPANY,INC. A� FROM f. To ft DIAMETER InI TIRCKNESS MATERIAL
�J sa'3 ie (Jlll)
Company Name �l-ifi0i(y+,3fieL�i1 t roce
///�yyyy V J rR C,,r_,r�iOJ1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: n 4Y 7 �,i4
".,.. FROM TO DIAMETER T�CICVESS NIATERIAL
List all applicable well constntction permits f.e.UIC,County,State,Variance,etc..) /ft. �,}ft. -t �,Pn• 3 V ( P
3.Well Use(check well use): I ft. l ft. in. v
Water Supply Well: 17.SCREEN
FROM _K
TO DM vIETER SLOT SEE THICNi ESS RL-17ERLAL r
❑Agricultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. ft. i�•
❑Industrial/Commercial ❑Residential Water Supply(shared) 13 GROUT
❑Irri ation []Wells>100,000 GPD FROM TO IIIATEa 1L I EMPLACEMENT METHOD Fs AMOUNT _
Nola Water Supply Well: ft. ft. yrde^d�L r S so 61 VIC.-l/ p
❑Monitoring ❑Recovery ft. ft. ���,�6 y L J ptr®e� C
Injection Well: ft. It.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT NIETHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, .in size,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remazks) 19 ft. ft.
4.Date Well(s)Completed:3'12" Well ID# D ^ `A.il ft. ft
5a.Well Location:
/' ,Phone #3j[O L�� L&34 9S ft. jai ft. Fyl �
h�./"y t /GL i�'T� � �' � � .� ft. dLo
Facility/Owner Name D FacilityID#(if applicable) 6� 6 a ft, 6-3 d ft. r- ^ ��/�
S7�il C y �l �C 9 5-c, JGPb l OP� 6?d ft. ®� ft. -cv�
Physical Address,City,and Zi� ft. ft.
21.REMARKS
County Parcel Identification No.(P1N) '.
?�� L e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1Ie i �° Gar ail 6
(if well/field,one lat/longtiiss sufficient) 22.Certification:
3 �iDAD N I LO 734 W
6.Is(are)the well(s): kWermanent or ❑Temporary Signature of Certified Well Contractor 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 P° To 15A NCAC 02C.0100 m•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/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 l GW-1 isi needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
•drilled: L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ?0 (ft.)
For multiple wells list all depths if different(example-3@a 200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: F� (in.) Bit Off: 5 e �j I/ 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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WLLS ONLY: 24d.For Water Wells producing ver 100,000 GPD: Copy to DWR,CCPCUA
3� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i 1-
v DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount: OZ l n,
�t ®�'�'.s VISITED BY: V11
Form GWA --Wirth Carolina Department of�E-nyvironme tal Quality-Division of Water Resour/qes l Revised 6-6-2018
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