GW1-2021-00271_Well Construction - GW1_20211213

E ML+COLTS llJ UC 1T1I+DNRECORlT➢ (dvW-1) For Internal Use Only: ,}
Pj
I'Well Contractor Informntion:
Is K WATER ZONES
Well CoahactorN a FROM TO DESCRIPTION
ft. ft. f'
s4A ft ft
NC Well Contractor Certification Number
15,OUTER CASING for multi-cased webs ORLINF.R rf a licable
YADKIN WELL COMPANY,INC. FROM TO D1kMETER TIDCIO•iESS MATERIAL
ft ft. in, i
Company Name �y 16.E%Uaa CASING OR TUBING 'eothermal elosed400
2.Well Construed on Permit#:- A 7S y!Z4 FROM TO =00"ER I TRICIDWS I MATERIAL
List all applicable well construction permits(re EEC,County,State,Variance,etc) ! ft &ft in
3.Well Use(check well use): ft ft, in,
1
17.SCREEN
Water Supply Well:
4110M TO DIAMETER SLOT SIZE T1namss MATERIAL
PJAgricultural OMunicipal/Public ft. ft.
xci aieotiiesmal( eah1lgJCooling Supply):,: *eiidantial Water Supply(single) ft R. in.
,11.U' jAiie rial/Cdrrb--hercial DResidential Water Supply(shared) 18.GROUT
20
0i igation Dwells>100,000„GPD PROM I TO MATErGAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 00, ft --r
DMonitoring DRecovery it ft.
Injection Well:
ft ft
DAquiferRecharge OGroundwaterRemediation 19 SAND/GRAVEL PACK Wapplicable)
❑Aquifer Storage and Recovery ❑Salmiiy Barrier FROM TO MATEATAL EMPLACEMENTM=01)
gAquifer Test ❑Stormwater Drainage ft ft.
OExperimental Technology ❑Subsidence Control fL ft.
DGeothemmal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necevsa
❑Geothermal(Heating/Cooling Rctmn) ❑Other(explain under#21 Remarks) oM xo DESCRIMON(solar,hardness,soiVrocktypr,Unin si e,ace
q 42.ft. 1303 ft rd.,. G
4.Date WeU(s)Completed: 117y oP I: Well ID# w�0—! T I ft.fL ft
ft
5a.Well Location: Phone # I rn
P)4WAV �'�niw-r-A 1C�7820 ft ft P E C 13 202a ,.
Facr7ity/OwnerName Facrlifi]D l(if applicable) ft ft-
ft.
Physical Alress,6y,and zap ft ft.
2L REMARKS
County Parcel Identification No.(PIt-D 3 0�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
3G a e4-4?3 N �1 ;.5, 510 W W xtA5
6.Is(are)the well(s): Aermanent or DTemporary Sign re of 4extificd Well Contractor' Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eldsting well: I or ANdt v L't^ 15A NCAC 02C.0100 or I SA NCAC 02C.0100 Well Construction Biia7dai and that a ropy
Ifthis is a repair,fill out known well construction motion and erp/am the nature of the of this record has been provided to the well owner.
repair under f2l remarks section or on the back ofihisform.
23.Site diagram or additional well details:
B:=For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction mfo
cdiistruction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remaria Box).You may also attach additional pages if necessary.
drr7led: I 24.SUBMITTAL INSTRUCTIONS
"9.Total well depth below land surface: 1303 (ft.)
For multiple wells list all depths lfdifferent(example-3@200'and 2®100) Submit this GW-1 within 30 days of well completion per the following:
�� ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) hmformation Processing Unit,1611 MSC,Raleigh,NC 27699-1617 Q:+
Ifwater level is above casing,use"+" p
11.Borehole diameter: �p (in.) Bit Off: 5".26i ? 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) q;
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Retufu Wells:Copy to the
(Lt.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing,over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: d✓� Permit Program,1611 MSC,Raleigh;<NC 27699-1611
t
o OZ DATE SITE VISITED: :z