GW1-2021-02353_Well Construction - GW1_20210722

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CtCoi�TSTil8P tJC T ®NY RF-C �CW--I For Internal Use Only:
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1.Well Contractor Inforrnahon: i
�WL Pl 614:,NYATERZONE9 ." • '; n; `,r , .a.: r l
Well Contractor Nameft.t FROM TO DESCRIPTIONy
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Li � � � 021 �ft. S ft.ft- � � �
35 A 3UL L w 2 � 77 � (o
NC Well Contractor Certification Number 45.+OUTER CASWG for`miilti sed wells TOR LINER"if irRli file 5„
YADKIN WELL COMPANY,INC. 31tOT1 r .r S ng Unit FROM TO DIAMETER: TRICKINESS MATERIAL
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�il{t7ff7l lf,j'An ft. ft. in. {
Company Name :16-INNER CASING OR TUBING eotbermaLrlosed loo 3i'-,r �` ^i IeAok j
S(9 METER THICKNESS MATERIAL
2.Well Construction Permit#: FROM TO DIACp 11 "
List all applicable well construction permits fl.e.U1C,Coun ,State,Variance,etc.) ft. 3 ft 2J V to
3.Well Use(check well use): ft' ft' 1°'
1 '17.SCREEN
Water Su
pp Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATEIIAL
❑Agricultural ❑Municipal/Public ft. ft. in. :{
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTy f
Non-Water Supply Well: ft. ft. a� e,t �• �h� S O,w�G',s�`M
S
❑Monitoring ❑Recove ft. 30 ft-
eyigf
Injection Well: }
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL'PACK if a'"livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IMATERIAL EMPLACEMENTMETHOD• s
❑Aquifer Test ❑Stormwater Drainage ft• ft. ` s
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer '20 DR1LL•INGLOG attach add,t,onelstieet3"if,necessa 31� r
FROM TO DESCRIPTION(color,hardness,aoiVrock e" n aaq etc .i.;r?3r.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft. ' s - L�
V fD r QL b CIA.
�d ; Kra
r] y, A ,
4.Date Well(s)Completed: 5—P r A Well ID# — �/ ft. ft. 4 '( Y z .(�
�� 16 ft. 40 ft. •y�, /o ��!1/ G st a •
5a.Well Location: ]�Phone
# d��-�/(�8/'jj CObq-'Cbt �r/1✓C . #rg_T_ -'C Yll� h w �Uft (� ft �'01
Facility/Owner Naame FaciL ID#(if applicable) 0 ft. oil eS ft. r i Let, tt-4r7
C7 Ch1 14G� 5-ft. l ft �i�4 1'n
N-tof
Physical Address,City,and Zip !r✓7/
21:REMARKS '
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Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: V S
O N 2? 36 Y10 W :.
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordan with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that ao
coe
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form. `a Q
23.Site diagram or additional well details: ^
You may use the back of this page to provide additional well construction
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction only 1 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 INSTRUCTIONS _
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9.Total well depth below land surface: / (ft') Submit this GW-1 within 30 days of well completion per the following: r
For multiple wells list all depths if different(example-3Q200'and 2@100D
10.Static water level below top of casing: Ty (ft) 24a. For All Welts: Original fond to Division of Water Resources (DWR)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
If water level is above casing,use
Bit Off: 1' (! 24b.For Injection Wells:Copy to DWR,Underground Injection Control
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY w
24c.For Water Supply and Open-totip 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,CCPkCUA r
o +-
�) Permit Program,1611 MSC,Raleigh`NC 27699-1611
13a.Yield(gpm) Method of test: lfLr F�
70%HTH OZ DATE SITE VISITED:
13b.Disinfection type: Amount: h� .
S VISITED BY: UB
Form GW-1 _ — N�h'Carolina Department of Environmental Quality-Division of ter Resources Revised 6 6-2018