GW1-2021-02728_Well Construction - GW1_20210809

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WeII Contractor Name _-..__...._...__ _ __. Tq.__.viz __ i of l
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NC Well Contractor Certification Number �
15.OUTER CASING for multi-cased wells OR LIIVGR �a pGetrble
O��� FROM To DIAMETER croacss Ts
YADKIN WELL COMPANY,INC. nJ'�` c�
Company Name
n/ 16. CASING OR TUBING otbermal closed-loop)
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2.Well Construction Permit#: a FROM To I)LUMTER THIGO S I NUTERrAL 1,
List all applicable well construction permlls rLe.TAC,County,State,Valiance,etc) ' Zg ft. t 'a- L _ PV �+
3.Well Use(check well use): ft. ft. m, i1
37.SCFS2i'l
Water Supply Well: e e ON TO DIArAZTEa SLOT SIZE Ta'rC1cf ss r:1-Ii1111L 7/
❑Agricultural ❑Municipal/Public ft. ft ire•
❑Geothermal(fieating/Cooliug Supply) Residential Water Supply(single) rt g
01ndustrisUConmmeroial ❑Residential Water Supply(shared) iq GROUT
❑Irrigation ❑Wells>100,000 GPD rsmorrl TO mATGR4*_V EnPLACe,W-E aT t:MTHOD c,1-tOUN T
Non-Water Supply Well: tt' 3' ft
❑Monitoring ❑Recovery 3 23 ft
Injection WeU: ft. ft
❑Aquifer Recharge ❑Groundwater Remcdiation
19.SAS+/G)RAITL PACE:(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier reor.I TO MATERIAL cr. E ACEraW i rrMMOD
❑Aquifer Test ❑Stormwater Drainage R'
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if oeressa
❑Geothermal(lleating/CoolingRehun) ❑Other(explain under#21 Remarks) PROM To DESCRIPTION color,hardness saa/rark type,rain size,eta
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ft
4.Date Well(s)Completed: ��Well 1D# ^57� Z ft' 3 � Q
S�S�jnL
Sa.Well Location: Phone # 710 ft'164Q� 31 ft 90 11
it X ri'lo-8a`?�-S`tr® 0 1&7 A,
Facility/Owner Name Facility ID#(if applicable) R' ft
ft. fr.
Physical Address.City,and Zip
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I sh e- .2L REMARKS
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lat/lougg iis's�sufficient) 22.Certification'
?,t?rR 1 G / 3 N ?Z 23v, Ki� fKZ W - �—� -7-13e21
Signature of Certifi
6.Is(are)t.bewell(s): Atermanent or ❑Temporary
Well Con tar Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or Ppo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,fill out known well construction information and explain the nature of the ofthit record has been provided to the well owner.
repair under#21 remade section or on the back of thisform.
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 well construction info
construction,only 1 GW 1 is rded. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b (ft) Submit this GW-1 within 30 days of well completion per the following:
Fornni tiple wells list all depths ifdifferent(e=ple-3@20 'and2(tr)1001
3 (�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level it above casing,use"+" I
11.Borehole diameter: (�) Bit Off: 6 ' 12 311 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Wellconstruction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,eable,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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 2 Method of test: a A✓ 1 j J.�� a
13b.Disinfection type:
70%HTH Amount: 1 L OZ DATE SITE VISITED: J 141AC—
Ma* T("i VISITED BY:
Form GW-1 AMMON,.. North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018