GW1-2021-02394_Well Construction - GW1_20210722

Well Contractor Name ��, � s FROM TO , i Fir Mil
3 3 6 A ft. rt. :o z �. r
NC Well Contractor Certification Number 110,
e�rOOC 15.OUTER CASING for multi-used ORLFIVER"ifa pfi&W wwa
YADKIN WELL COMPANY,INC. ^3'vP ��� FROn4 To MOWER sjKATMIAL, Lle
ft• r �`��
Company Name j11.r vi'a
�,( 4/ 16.nWgER CASING OR TUBING( thermal d6sed-loo`
2.Well Construction Permit#: 3 ,5 G � FROM I To DIAR=, R I THFCIMss MaTERIAE* :am`�'
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) IL in- :S
a kx,a8
3.Well Use(check well r•.se): ft. ft in. "M ,
Water Supply F1'e!! li.3C1'E,ii i a H sK
F-Ror.I TO" DIAPArTER i SLOT sEs.E •TzjcxriEss e- ri:l.. !1:R!A d '
❑Agricultural ❑MunicipaUPublic ft. rt irr. u a
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft in. , ,
❑TndustriaUComm�mercial ❑Residential Water Supply(shared) `'VIE
�
3b.GROUT
❑Irrigation ❑Wells>100,000 GPD MON TO PIA TEW.L Er'�'LAC3n1Et4T-r.>✓^eSeD"CP1.IOUPtF,�
Non-Water Supply Well: fl' 3 fi BteyW& W41 ��
❑Monitoring ❑Recovery 3 f4 .2 It
Injection Well: ft. R
1r
❑Aquifer Recharge ❑Groundwater Remediation
19.SAPiD/GRA4,TEL PAC-1(Lf a fticoblc
❑Aquifer Storage and Recovery ❑Salinity Barrier coral TO NATERUL 'EMPLAM,- 4F,h1ET30D
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control tt �
❑Geothermal(ClosedLocp) ❑Tracer 20.DRILLINGLOG(attach additional sheets irueceasa t
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) steams To DESCRIPTION color bareness;soNroetr " T`elnTsde'�ete !1i F
V
4.Date Wells Completed: 2� Well w# AQ-St s'
5a.Well Location:
Phone #5'�9•V`l l3 l7 ' 3 0 ft nr► � ,S
MIN e
of
Facility/Owner Name Facility ID#df applicable) R ft. n ,
i
1479 W i l W � �.P.r,,, a►�o 2S L1 ft ft.
Physical Address,City,a kd Zip i
21.RRMARXS
_Q 1k,01
County Parcel Idenitification No.(MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: 3
/ / ��99 2 r a, � •.
W
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date .
si m this orm,Ihereb ce #p`
BJ+ gn'g f y reify that the weU(s)was(were)cons6 ttcled in accocdmtce:with
7.Is this a repair to an eristing well: ❑Yea or ,VNo ISANCAC 02C.CI00 or 15A NCAC 026.0200 Well Conserucrion Standdrds at acopy
Ifthis is a repalr,fill out brown well construction information and erplain the nature ofthe ofthis record has been provided to the well owner. `
repair.under#21 remarks section or on the bark of this form. r A.43
23.Site 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 wellrtruchon info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach adrlittoilal pages Ifnecessary.
:.r
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 310
(ft) Submit this GW-1 within 30 days of well completion er the fopovn
For multiple wells list all depths if di,�-erent(ar=ple-3@200'and 2@100� y P P
10.Static water level below top of casing: Q (ft.) 24a. For All Wells: Original fermi to Division of Water Resources
Ifwarer level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigb,NC 27699
: Cs QJ�J 24b.For Injection Wells:Copy to DWR,Underground In ection Conir0l
11.Borehole diametei: (� (in.) Bit Off � 1.
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY ,
12.Well construction method: 24c.For Water Supply and Open-Lnop Geothermal Retain Wells 1C16py o'the
(i c.auger,rotary,cable,direct push etc.) county environmental health department of the cou where installed nty
FOR WATER SUPPLY WELLS ONLY: E w
24d.For Water Wells producing over IOO,OOD GPD:Copy to DWR,CSPGUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 6 Method of test: a i d'
13b.Disinfection type: Amount: k
70%HTH OZ DATE SITE VISITED:
;&G K46)0ITED BY: I
a `
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResources I 4P Revised 6 6-2018
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