GW1-2021-02738_Well Construction - GW1_20210809

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Well Contractor Name ry '
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NC Well Contractor Certification Number �C, �? .8�
�\ 15 nU1�RtCr�41P1G form Dfi- at�TERm�.: TEIC[INL✓35 a Iiurb Rrax•FRO '.
YADKINWELL COMPANY,INC.
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Company Name d V 16.INNER CASING OR.FUSYR1Qr( et hermal closed-loop)`
`C 0 goo FROM TO pe UARM MC5�55 1it(A�YAAL
Z.Well Construction Permit#: � g
List all applicable well construdian permits(Le.UDC,County,Slate,Variance,etaJ F In
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3.Well Use(check well tse):
17.8C1tE2?I ,
Water Supply Well: MON TO D METE.-" SLi3T SIs E TTiC;Ud- R9r:TrPPS?i. '
❑Agricultural ❑MunicipallPublic ft. ft ' Ile•
❑Geothermal(Heating/Cooling Supply) M sidential Water Supply(singe) ft. ft i0
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.:C-r<Q3ITa
❑Irrigation ❑Wells>100,000 GPD FROM TO R4A 6Et;R,+c E10LACErMT PET-ROD&A1dOUNT
Non-Water Supply Well: ftte
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❑Monitoring ❑Recovery e1 rY ®a 4
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation gg gpSO/daRA�'E1 FAG (if a 9ieable
❑Aquifer Storage and Recovery ❑Salinity Barrier e�oPr To", mATEAImAL ". LTffiLPCEItBtdrtrmeMOD
❑Aquifer Test ❑Storinwater Drainage '
❑Experimental Technology ❑Subsidence Control
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❑Geothermal(Closed Loop) ❑Tracer 20.DRIUMIGLOG attach add'iCitlnalsheetsif ueerssa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under g21 Remarks) FRons To' aBserafonr eomr haedaeta°6aWroeic see,�e
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4.Date Well(s)Completed: m 1 Well ID# ft. 6f t9
Sa.Well Location: Phone
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Facility/Ovmer Name Facility M#(if applicable)
Ph cal s//,City,end Zip f$ &
Goanty Parcel ldeatification No.(PIIi)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22:Certafisati0n:
6.Is(are)the well(s): ermanent or ❑Temporary Sigaahae ofZdW0,Ccmbwtor• Date '
Bysigningthisforni,l hereby certify that the well(s)was(were)cossftrxed in accordance with
7.Is this a repair to an exMng well: ❑Ylea or �Io l5ANCAC 02C 0100 or ISAIPClC 02C.0200 r*ell'Coastrii6iii ih ds Standm and that a copy
If this is a repair,fill out known we!/construction information and explala the nature of the of tlriv record has beat provided to the well owner.
repair under#21 remarla section or on the bark of this form. 23,ft dingr or addil iODsTwell details:
8.For GeoprobellDPT or Closed-Loop Geothermal Wells having the same YOU may use'the back of this page to provide additional well constrtrctaninfio
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwas (add'See Over in R Etdm Box) You may also aftchadditional pages if nimsary.
drilled: b" ® 24.SUBMITTAL INSMUCTTONS
9,Total well depth below land surface: VI (ft)
For multiple wells list all depths if different(example-3Qa Zoo,an @100) Submit thin GW Y within 30 days of well eompleti on per tare following:
a4 ( � 24a. For All /elTe -Osigmal fioim td Divi<sioti of Water Resources (DWR),
10,Static water level below top of casing: Information Processing Un%146117 46 Rsleig AIC 27699=1617
Ifwater level is above casing,use
11.Borehole diameter: (in) Bit Off° �e 24b.For Infection Wells.Copy to DWR;Underground Injection Control(IUC)
Program,1636 Mr,Raleigh.NC 27699-i636
AIR ROTARY
12.Well construction method: 24e.For Water Supply and Opeffi-]troop Geothermal Return dells:Copy to the
(ie.auger,rotary,cable,directpusb,etc.) county eaAm=ental health department ofthe comttywhere installed
FOR WATER SUPPLY!WELLS ONLY: 24d.For Water Wells li oducing over 100,000 OPID:,Copy to DWR,CCPCUA
Permit Program61611 MSC,Raleigh,NC 27699 16I1
13a.�dd(gem) lYdetbodoftest: ��� �
o DATE SITE VISITED;
13b.Disinfection e: 70/o HTH Amount: OZ ;
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VISITED BY:
3 �' -7. �.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoortes ;' Revised 6-6-08