GW1-2021-05270_Well Construction - GW1_20210503

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NC Well Contactor Certification Number 15.OUTER CASING for TKIfi, sedIvells)OR R 11 applicable) 011�
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YADKIN WELL COMPANY,INC. I I I ERIAL
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Company Name 16.EOM R CASING OR TUBING(i i eothermal closed-loop)
2.Well Construction Permit#: FROM TO DLA METER TIUCHNESS MATERML
List all applicable well construction permits(ie.UIC,County,State, Variance,etc.) lj ft. 5-47 ft• in. tv
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 37.SCREEN
rRop'l TO MAP-JETER SLOTSIZE TH-Ic-t4-1ESs i3v--TEnLa-L
DAgricultural 0Municipal/Public ft. ft.
00cotherm-al(Heating/Cooling Supply) OResidential Water Supply(single)
ft.
DIndustrial/Commercial Residential Water Supply(shared) 16 7G-RC,U T
DIrrigation OWells>100,000 GPD FRO 11.1 TO A-'�T ERIAL EPIPLACEPMITM-TEOD�-U-10TWIT
Non-Water Supply Well: ft. W-.� ! ;.
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DMonitoring CRecovery ft- sl ft a
. .4#,, P
Injection Well: (I ft. ft. LLL!� pp
DAquifer Recharge []Groundwater Remediation 19.SAND/CRAVE L PACH(if applicable)
0Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERLUL EMPLA(M-WENTAIrTHOD
OAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control
ciGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additiodal sheets if necessary)
DGeothermal(Ileating/Cooling Return) 0 Other(explain under#21 Remarks) oaf TO I DrSCRITTION(color,h..rdness,soillrock type,grain size,etc)
ft.
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4.Date Well(s)Completed: q-/C�-OI(- Well ED#.�,4/1T6-'/4Z ft 1"eoo,' z' 4-o
ft. ft. i
5a.Well Location: Phone 0,5�7-YqC,!i so - ,=in
/<-e-�/y -4-4 n e-5 ft. ft kJL-
Facillty/OwnerAme Facility ID#(if applicable) ft. ft.
Ay X 3 2021
U1 111
fL ftPhysical Address,Ci�,and Zip
V'A 21.REMARKS
�&�L. 09a poe-kf I N
county, Parcel Identification No.(PIN) '2iUJ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N :W
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SifflF6.of Cered Well Contractor Date
6.Is(are)the well(s):Xpermanent or OTemporary By signing this form,I hereby certify'that I the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0yes or JkNo 15A NCAC 02C.0100 or IJA 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 bark 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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -(ft-) Submit this GW-1 within 30 days!of well completion per the following:
For multiple wells list all depths itdifferent(example-3@200'and 2@1 OOD
24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf (i
water level is above casing,use"+" r- ) Bit Off: 24b.For Injection Wells:Copy tolW11 D i ,Underground Injection Control(rUC)
11.Borehole diameter: (0 n. Program�1636 MSC,Raleigh,NC 27699-1636
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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
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing 'ver 100,000 GPD:Copy to DWR,CCPCUA
WELLS
Permit Program,1611 MSC,Raleigh C27699-1611
13a.Yield(gp-) Method of test:
70%HTH Amount: Oz DATE SITE VISITED:
13b.Disinfection type:
VISITED BY:
Form GW I North Carolina Department of Environmental Quality-Division of Water Resources 1 R ' d 6-6-2018