GW1-2021-02352_Well Construction - GW1_20210722

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NC Well Contractor Certification Number 15.OUTER CASING(form ulti-casel
wells OA LINER(if applicable
+ FR0114 TO DIP_R•I);TI':R THICIOVESS MATERIAL
YADKIN WELL COMPANY,INC. �` � 21
e
•r 2� fit. ft. I An. i
Company Name �j,OCess%ng UM, 16.INNER CASING OR TUBING 'eothermal dosed-loop)
2.Well Construction Permit#: ot10I1 •- FROM TO DIP_11IETER THICI(NESS MATERIAL
List all applicable well constriction permits(i.e. C,Count iaance,etc.) ft. ft. e f v
• O (9QJ
3.Well Use(check weal use): ft. ft in.
Supply
Water Su W 17.5CRE i 1
pl Yell: Friorrl TO D1-1,?JETER SLOTSIZE TITiCMOd_SS HATE
❑Agricultural ❑Municipal/Public it. ft. in. C
❑Geothermal(Heating/Cooling Supply) Aesidential Water Supply(single) -it. It. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEP:M-NTA,=P OD a ALIOUPIT
Non-Water Supply Well: 0 fM. Al ft. 1401t PI VC, Fovr'ed v' ba S
❑Monitoring ❑Recovery LI ft. aVlCk
ft. O °
Injection Well: ft. ft tour rV S:n 4
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAIrEL F A CIL(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO@1 TO I MATERIAL EP.•IPLACETYf NT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft•
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) } -
FRORI TO DESCRIPTION color,hardness,soil/rack typr,grain size,etc-
❑Geothermal(Iieating/Cooling Return) ❑Other(explain under 421 Remarks) ft. O ft. !r
4.Date Well(s)Completed:G i-15 Well ID# Kpv J J& 40 {t 2 ft-
f-anAr
5a.Well Location: / Phone ft It.
Facility/Owner Name Facility M#(if applicable)
Meg b e
Physical Address,City,and Zip ft. ft
/ 21.REMARKS
et
County ParceLidentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34 al. N 1'l 1�. (� ?Z-Z w
6.Is(are)the well(s):Prr
ermanent or ❑Temporary
Signa of Certifitd Well Contractor. Date
By signing thisform,I hereby cemfy that the A/(.)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orAp
0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Iviown well construction information dnd explain the nature of the of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additionai well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pajE'.to provide additional well construction info
construction,only 1 GW- is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yotimay also attach additional pages if necessary
drilled: 24.SUBMITTAL INSTRUCTIONS; '
(ft.) Submit this GW-1 within 30 days of wellcompletion per the following:
9.Total well depth below land surface: 1-1 a� .;
For multiple wells list all depths lit different(example-3 r©200'and 2@1000
/b 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
]f water level is above casing,use
Bit Off: L 7 24b.For kiection Wells:Copy toIDWR,Underground Injection Control(lUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636„ "
12.Well construction method: AIR ROTARY i
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 106,000 GPD:Copy to DWR,CCPCUA
k Permit Program,1611 MSC,Raleigh,NU-27699-1611
13a.Yield(gpm) 3 Method of test:
70%HTH ' OZ DATE SITE VISITED:
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourbw Revised
to