GW1-2021-02424_Well Construction - GW1_20210615

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1..._.-_a..._._...___._.._._._._..___.._._...._........_._._._... !'lxoct TO J::srrrt"•rtalt fL.�'
well Contractor NV
3 ft. r f ft s .e� _
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LAVER(if a placable
YADKIN WELL COMPANY,INC. FROM To D1A 4=,R T81C1cNEss TGRrAL tf
ft. ft. in.
Company Name
16,INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: d 4 FROM I To r DIAMETER T$t OMSS MATT-MAL
List all applicable well construction per nil's T e.t11C,County,State,Variance,eta) G ft `7 ft tj}.s in` C� "^I
3.Well Use(check we±I t.se): ft. I ft; in.
®crater Supply Well: 17.SC3 Eal
FROM TO DL`.r:LMI SLOT SIM Ti11CNES t:I •1•ssltLAL
OAgricultural OMunicipallPublic ft. ft. in.
t7Geothemmal(HeatinilCooling Supply) Residential Water Supply(single) it. ft
01ndustrial/Commercial DResidential Water Supply(shared) lb.GROUT
OIrrigation OWeils>100,000 GPD Feon1 To RATER EMPL ACEMIE1aT rTEETSOD is AMOUNT
Non-Water Supply Well: (� ft. 5— ft. 96a- c1.r
OMonitoring DRecovery ft Dk-{ ft.
Injection Well:
ft. fl.
DAquifer Recharge OGroundwater Remediation
19.8rrSiD/GRAWEEELPACIi:(efa plicabic
OAquifer Storage and Recovery OSalinifyBarrier FEON TO MATEML I EPIIMACEVMITm>LrROD
OAquifer Test OStormwater Drainage ft ft
DExperimental Technology OSubsidence Control ft. ft
OGeothermal(Closed T.00p) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(I�eating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO f DESCRIPTION rotor,hardness,soiltrock is siz etc
!_ f 1 Q ft, A fL so Ift p1�, 6-elx
y i
4.Date Well(s)Completed: �'f��D` { Well ID# Al�—; t b ft• ft•
5a.Well Location: �,,,� Phone # ;��'-f�7 3 8 a�'' I g � � a L.1'
it. ft.
-'`r'evt.a v .T`wit ex
Faclity/0� ewr Noma ( Facility ID#(if a�prp�li/cab ft, ft.
/le) e�
��hd f3�t•tra, �O14�Q �''33G•O Tor" '� ft, ft.
Physical Address,City,96d Zip M
21.R XAARES
County
��/k C_ , Parcel Identification No.gW)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweII field,one latAmigis sufficient) 22.Certification-
6.Is(are)the well(s):Permanent or OTemporary orcertif4wau contracmr Date
IREC E N i rg thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or Aqo 15A NCAC 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well constructtan information ollrdgmplabi the Q o a. U record has been provided to the well amen.
repair carder 921 remarks section or on the back of this form. r✓'` I J ?`-��
23�Sitile ddiagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells ;M PrOCeSYb 1'&e the back of this page to provide additional well construction info
coastruction,only 1 GW=1 is needed. Indicate TOTAL NLINMER of I1,A SeC`U(Wd'See Over'in Remarks Box).You may also attach additional pages if necessary_
drilled: j ^� 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: a`4(3 '0 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple w ells list all`depths tf dif fervd(example-3@200'and 2Q100)
l$°'r 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11.Borehole diameter:__ (in.) Bit Off: 5. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 276'99-1636
12.Well construction method: AIR ROTARY
24c,For Water Supply and Open-Ldop Geothermal Return,Wells:Copy to the
(it.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 �{
I Permit Program,1611 MSC,Raleigh, C 27699-161, Q
13a.Yield(gpm) f�-- Method of test: ti•f f% 4
70%NTH Amount: �,p o2 DATE SITE VISITED:
13b.Disinfection type:
,
VISITED BY:
Form GW�•1 _.,-n .';, rrryk..-lma Department of Environmental Quality-Division of Water Resources Revised 6-6-2
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