GW1-2021-02653_Well Construction - GW1_20210809

�_._._• IT" J
�_�. n��Lls__.__.
,_.
-- - - - _
We11 Contractor are -..-- ��-�-- T�i:C�r.l TO i,'eSCi�TiDi l
1G�ft. ocr it.
5�7 �� ft. I q11 ft_ /.1 t N X s_ Ste' e.4
NC Well Contractor Certification Number 15.OUTER CASING for multi-ease ells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROn4 To DLATMT'ER TIiICIOVEss TERIAL
/� •� _ ft. ft � in.
Company Name D of 6J 3 t '' ! 3- 1G,11NIYER CASING
OR TUBING( thermal dosed-Ioo
2.Well Construction Permit#: 332. -7 FROM To DMNETER Tffi�4QES5 MnT1:RL4L
List all applicable well construction permits(i.e.WC,County,State,Variance etc.) h ft r^L� 1n- 9 L (�
3.Well Use(checlt well ase): ft. ft in,
17.SCr-TEN
Water Supply'Well: rROL-; TO DL'_IETeR SLOT SIZE TO-10171EsS • P.I.-I-TVP 07
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) /esidential Water Supply(single) It g, in. (�
❑IndustriaUConimercial ❑Residential Plater Supply(shared) 18,Cr.UUY \"
❑Irrigation OWells>100,000 GPD reoai TO PIATERIAL EMPLACEr:MNT nTT1101)cA&IOUNT „o
Non-Water Supply Well: f'• y It �(..` 0 U
❑Monitoring ❑Recovery IL
34 It 1011.g
0R iJ
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAJ11D/GP..A.1'EL PACK(if appGrnble)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. MMIF _Cil',Mrr mETUOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft _
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DFSCRLPTION color,hardness,soittrodc typt,grFin sva,eta
❑Geothermal(Aeating/Cooling Return) ❑Other(explain under#21/R�emarks) O f. 0.ft SZL:L
4.Date Well(s)Completed:]_ Well 1D# AAb O/0 7o f{ e Se) kns
ft
Sa.Well Location: Phone # ft
r PZ->�y
ft ft.
Faccility/'OOwnerName Facility
IID#(if applicable)
� ft• ft {�
L 0 L AG.Lk ac4 cc4ea.k ( � fG ft r
Physical Address,City,aid Zip ft ft p 1 G
v1 �/LQi 21.REMARKS
County Parcel ldeatifi cation No.ON) [1i••2!n'3t10'tl Ca��!On
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laWong is sufficient) 22.Certification:
3V .ST,. ON N 9-a4' 3 7, 17 2 w
6.Is(are)the well(s): dermanent or ❑Temporary S- of C ed ell Contractor Date
signing this form,I hereby certify that the well(s)was(were)eansdvcted in accordance with
7.Is this a repair to an existing well: ❑Yes or 9D 1SANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fdl out laown well construction information andexplabi the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisfoym.
23.5ite 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 well construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ���, (ft) Submit this GW-1 within 30 dais of we11'com completion per the following:
For multiple wells list all depths tjdiffer&d(trample-3@200'annd 2(e)100� Y p p
10.Static water level below top of casing: /�C) (f>~) Ma. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+/" Information Processing Unit,I617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: to (in.) Bit Off: �.GJIS 24b.For Infection Wells:Copy Ito DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
AIR ROTARY
12.Well construction method: 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 offihc county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produein I over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611 in a 3
13b.Disinfection e• 70%HTH Amount: OZ DATE SITE VISITED: 1.-
l
ri-aq• al
VISITED BY: DC-A
Form GW-1 North Carolina Departure of Environmental Qualityw Divis' of Water Resourcrl evised 6-6-20 8
IPP.ICEi r_ � PL. 1A.frC¢v /' LLoa' -x 100Ae )