GW1-2021-02348_Well Construction - GW1_20210722

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Well ntractor N e
NC Well Contractor Certification Number
I PSOcesslnO U S.OUTER CASING(for multi-cased ivells)OR LINER(if applicable)
YADKIN WELL COMPANY,INC. r FROM TO DIANETER TEaCME,_
DIN cj cv,0 n ft. ft. in. MATERIAL
Company Name I
16.INNER CASING OR TUBING(geother ai dosed-loop)
2.Well Construction Permit#: 3 FROM TO DLUVICTER TMCKNEss MA-1-RIAL
List all applicable well construction permits(i.e.UX,County,State, Variance,etc.) ft- 3(o ft- (0 )-e- 5 OR-W
3.Well Use(check wc5'11 use): in,
Water Supply Well: 17.SCIRIE N
ry"OT1.1 TO DIUMIETER SLOT SIZE TMCMIESS PAATERiAL
OAgricultural OMunicipaUPublic
PGeotheimal CHeatinglCooling Supply) Pesidential Water Supply(single) C
01adustrial/Commercial DResidential Water Supply(shared)
[]Irrigation OWells>100,000 GPD FRONI TO ilM TERIAL EMPLACETdENT NM THOD_2,A&IOUNT
NOR-Water Supply Well: 12 ft.
DMonitorin DRecovery
`
Injection Well: ft. ft. !7
DAquifer Recharge OGroundwater Remediation L.9APID/G-P-1VEL PACK(if applicable)
DAquifer Storage and Recovery DSalinity Barrier FROM, TO MATERLAL
ClAquifer Test oStormwater Drainage
DExperimental Technology OSubsidence Control
oGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal 04eating/Cooling Return) 0 Other(explain under#21 Remarks) MOM --- TO DESCRIPTION color,h.�dnm,soil/rock type� in size,etc)
V to ft. ft
4.Date Well(s)Completed: Well ED# 10 ft. ft 170 - IM�
. 0
5a.Well Location: Phone #1704.3, -70ft 5-1 •ft. 111 eV J.4 9f J0&_*n
&Copae 1?0J1*4'a1Aer__ L&4-jW to d3ft'
Facility/Owner -9 ft. ft.
Name Facility ID#(if applicable) 1
t a-5 Ak/ob A Ad 5_26",Y ft. ft.
Physical Address,City,and Zip ft. fL
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
23, 3 N . q 7 z W
6.Is(are)the well(s):, Permanent or ElTemporary
, Mture of6Wrtifred 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 existing well: 0yes 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)mown w e 11 construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For Geoprobe/D.PT 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 INSTRUCTION:8
9.Total well depth below land surface: 03 -(ft
For multiple wells list all depths if&fferent(example-3@200'and 2@1 OOD Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5-6 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
Bit Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control (lUC)
11.Borehole diameter: (in..) Program,1636 MSC,Raleigh,NC 27699-1636
1
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
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) f Method of test: 6Cr N Permit Program,1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
II
VISITED BY:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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