GW1-2021-04230_Well Construction - GW1_20210415

1
WelI Contractor NameTo
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d ft.
NC Well Contractor Certification Number
15.OUTER CASING(for mule-eased wells Old LINER(if anirlienbie) 1
YADKIN WELL COMPANY,INC. n j 2021 FROTI To DIPS•ter?>R THICIrnrFss nIATcR�T
Company Name H ft. €t• in•
rr f 7 n essoo U 6.FfmEI?CAs tI1'�G OR TUBING
-I a:.. �C,.0
2.Well Construction Permit#: �j ,�.t1Il (>=other�al closed-loop)
!� C;r,.rjl�(1 bT:OBI TO DIA1l•LTI;R T&ICi4YrSS P�LATERIAL
List all applicable well construction permits(i e.UIC,County,State, , ;Cc,etc..) + I fr. ft. ` in.
3.Wel9 Use.(check well€,s_): ft. ft. in.
Watts•Si?�1rSy Well: 17.S+"RE2i`l
❑Agri, cultural ❑l/iunicipal/PubliC !f 1 _vf_.GiggS is ra_LiL \J
❑Geotherniai(=Heating/Cooling Supply) P t• r
--b Pp Y) �2..sidential Water Supply(single) �¢
ft. _
❑hldustrial/Cornmercial ❑Residential Water Supply(shared)
❑L-rigation ❑We I > a0.Gs i�UT
I s i00,000 GPD _r�:or:r To ,.,.,
EOGeothermal
ater•Supply Well: r T�'"''' `t0`=''- i:,riai irr-SOD;-FuvILUPtT
S7ft.
E11 c4i z S u�r
oring ❑Recover)+ -ft. 1
n Y0'ell: t M e, r-
r Recharge f ��
5 []Groundwater Remediation
r Storage and Recovery 1°.SOU GRAVE-L o-_�-Ce((if a.ai.-r ,
b ry ❑SalhrityBarrier - ----
r Test '`or.•r To P.T�T-z ii E-T-
�GS� ,-_i.rsula 1.rT7JD
❑Stormwater Drainage ft. fr•
mental Technology ❑Subsidence Control fr• fr
rmal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach addironai sheets if necessarr•)
rmal(IIeatinOCooling Retum) ❑Other(explain under#21 Remarks) raoni To DESCP.IFTION color,hardness,soil/rocic typf in size,etc
Z 1 'j OQ ft. ft. s a .
4.Date Well(s)Completed: J- 'Z'( Well EN -J ® �L ft. ft. r
33 .. 9a13 fr. ft. ei re [ �e
5a. ell Location: Phone
f &41./"e W fr. fr.
Facility/Ow(neerName Facility
/ID#(if applicable) ft. ft.
38 / l A
Physical Address,City,and Zip 51�7�l fr, ft.
- kfi`I e.S 21.RE-MARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
"A%A P ft,
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
i
By signing this form,I hereby certify that the well(s)was(were.)constructed in accordance with
7.%s this a repair to an existing well: ❑Yes or BNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 1 GW-1 is 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: 4•�- (ft.)
For multiple wells list all depths ifdifferent(example-3@a 200'and 2@1001) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use'+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: �i (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 I
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department�ofime county where installed
[FR;ATER SUPPLY WELLS ONLY: 24d.For Water Wells producint7 over�100 000 GPD•Co to D
Permit Pro am,1611 MSC,Raler NC 27699-1611 Copy CCPCUA
(gpm) Method of test: r/S cyt,/ gr -
ection type: 70%HTH Amount: OZ DATE SITE VISITED:Q6 5 VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
i Revised 6-6-2018
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