GW1-2021-05315_Well Construction - GW1_20210615

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Well Contractor Name ------ 7-r-.0il TO Dzs
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3036 A ;UN 1� 2021 3 waft. 4 S' Io 1
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I�C Well Contractor Certification Number 15,OUTER CASPIG(for multi-cased iV elis)OR L114ER(if applicable)
-r.3*U� pr_rr'SSing Un I FROM TO DLUILTER I TEUCICNrSS::�-TER�E&L
YADKIN WELL COMPANY,INC. Inforl on .- - fr. 1 1 in. I
Company Name 16,INNER CASING OR TUBING(g6ot.hermal dosed-loop)
2.Well Construction Permit FROM TO DLA METER I TffiCENESs TVDATr,.nreT.
List all applicable well construction permits(Le.UIC,County,State,Mariance,etc.) in.
3.Well Use(ChCCkW6R USE): fr. fr. in.
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37.SCREEN
Water Supply Well: rp.OH 7-0 !AAk.-1rTER FE-10-1—SIZEI TiT-CICIESS I HATErla-1,
DAgricultural OMunicipaUPublic ft.
DGeothemial(14eating/Coo ling Supply) OResidential Water Supply(single) ft.
01ndustrial/Conimercial DResidential Water Supply(shared) 0.GROUT
Olurigation OWells>100,000 GPD MORI I TO t.IATEPIAL PHIPTLACEfrIE PIT PjLETHOD&AJJOUNT
I
Non-Water Supply Well: 6 ie�I 1Z
0monitoring CRecovery 3 f'- -It. -3
Injection Well:
DAquifer Recharge oGroundwater Remediation 19.SAHER/CRAVEL PACI<_(!j_appficable)
DAquifer Storage and Recovery oSalinity Barrier Fpord TO J iATURULL ED. LScErmtagl KIETE—on
DAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology oSubsidence Control 60: f fL
oGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necess2n,)
OCTeuthermal(Ileating/Cooling Return) 00ther(explain under#21 Remarks
FROM TO DESCRIPTION color,hardness,soil/rock type,grain sae,etc.)
0 )0 It. C/47 4- S41.1-AS43111
4.Date Well(s)Completed: 29-,2J Well ID#AA0 ...........
Sa.Well Location: Phone # S.�v (3
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94,
Facility/Owner Name r facility DD#(if applicable)
ft. ft.
7—a!
Physical Address,City,add Zip 70 0 -ft. fL
y21.REMARKS
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3C '0 OT- 7,rl N 08-0 0 4/7, 49a W
6.1s(are)the weJl(s):)W-rm&nent or OTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(K,ere)constructed in accordance with 1;f
7.Is this a repair to an existing well: DYes or XNo 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 and explain the nature of the ofthis 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 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: 3
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
I
lfwater level is above casing,use Information Processing Unit 1617 1 MSC,1 Raleigh,NC 27699-1617
11.Borehole diametei: (in-) Bit Off: X, 24b.For Injection Wells:Copy to DWR.Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27 699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop
-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health m departent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing I o Ier 100,000 GPD: Copy to DWT,CCPCUA
13a.Yield(gpm) J Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type' 70%HTH Amount: 0z DATE SITE VISITED:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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