GW1-2022-01042_Well Construction - GW1_20220107

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ctor Name LEOCl TO L25Ci,_Tit}il
Well Contra ft.�
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ft ft
NC Well Contractor Certification Number
15.OUTER CA�IIrTG for multi-cased wells OR LW1 R if a livable
YADKIN WELL COMPANY,INC. FROM To DIANLPTt1t T>�crOaEssAUTERIAL
ft. ft.
Company Name
l 16.EgNM CASING OR T I1BWG'( cthermal dosed-loop)
2.Well Construction Permit#: (i(/ PROM To Dvu41xTLR I TlaMMESS 1vrn=RIAL
List all applicable well construction permits(re.UIC,C ty,State,Variance,eta) kl tt 103 ft Xiy 1D 2 1 'P V G
3.Well Use(chectc well arse): fr. R' in.
Water Supply'Well: 17.SCRl 2i 1
MOW TO DIRr.•1ETE1 SLOT SIZE TH-3Cla(ES0 11-TiIiir_L
❑Agricultural OMunicipal/Public ft. ft in.
OGeothemtal(Heating/Cooling Supply) gesidential Water Supply(single) it ft in.
01ndustrial/Commeroial ❑Residential Water Supply(shared) t o.Ci',GU e
❑Irrigation ❑Wells>100,000 GPD FROM To rv+TEW-1- EMIPLACEPM,NT P.42TROD f•PlioUNT
Non-Water Supply Well: ID it Gv ` VCe/ r,
❑Monitoring ORecovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GP.AVE,L PACK(if applicable)
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL E14%LACEr;iD4i hILenOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attacb additional sheets if necessary)
• ❑Geothermal Weating/CoolingRehun) ❑Other(explain under#21 Remads) FROM To DESCRIPTION color,bardnrss ooutrucic type,grain sae,etr
Al R ft ,-(
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4.Date Well(s)Completed: Well ID# rJ qyR' 30-'X-ft' /'Y� .4,qe ft. fL
r e�o
5a.Well Location: Phone # 33 d-KG�-=•
ft ft.
® Facility/Owner Name -Facility 1D#(if applicable) ft. ft
lea, ,��• ft ft. 1,� �_ �;.- \,/ I-
Physical Address,City,and,Zip ft ft 2,)
�,�keS• 21.RL+MARICS _
County Parcel ldcntification No.(PIN) 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
42
3 V ieG N �l' s S. 'i 1 '6 W
6.Is(are)the well(s): Permanent or ❑Temporary SOK of CeAdEd Well Contractor Date '
Bysigningthisjorm,l hereby cetttjy that the well(s)was(were)constructed in accordance with
7.1s this a repair to an existing Well; OYes or 0 15.4 NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
Ijthis is a repair,fill out known well construction information d e=Vlain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the bark of thisform.
23.5ite 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 OW-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: 3aa (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdifjereN(example-3Qa 200'and 2Va 100)
01 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of easing:
A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwater level is obese casing,use"+" )
Bit Off: (O•bar O 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-) 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 WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13s.Yield(gpm) f 1 Permit Program,1611 MSC,Raleigh,NC 27699-1611 u�
0 Method of test: Q `'
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pCrw
d
n
13b.Disinfection type: 70/o HTH Amount: / `�►. OZ DATE SITE VISITED:
_ VISITED BY: ! !
Form GW-1 rental Quality-Division of Water Resources Revised 6-6-2018