GW1-2021-02767_Well Construction - GW1_20210809

r
..----�^. -i �_. -_J- -=1-� -- - -s--. _ .._ � i filj�t•:•� i :lei V-1.._.. . . I -___
rRok.1 TO BFSCLuT!Oil i
Well Contractor N
►!/ 1. vr�
NC Well Contractor Certification Number `\(_ �soq 15.OUTER CA-SING for multi-cased wells OR LIraER if a licable
YADKIN WELL COMPANY,INC. P Q�t3 ,On FROA1 To D1AACTER '.THICT 11 MATERIAL
`fin, ? • tt. ft. in.
Company Name 30�� 16.INNER CASING OR TUBING(' othermal dosed-loop) t
2.Well Construction Permitk FROM TO DIPIIMTER TffiGFQiESS MATERIAL
List all applicable well construction permits(Le.WC,County,State,Yarlanee,etc) ft ft• in. J
3.Well Use(check well use): ft. ft, in.
Water Su 1 We[!: 17.SCREZ 1
fop y i'FOP; TO DU_NETLR SLOT SIZE Tolcig KK f:1-,TgP1AL
❑Agricultural OMunicipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. in.
❑lrldusttiaYCommeroial ORmidential Water Supply(shared) 18.GROUT
01irigation ❑Wells>100,000 GPD MON To rti+,Ert,�� Er�LacEr�rar r.TTgeD c al:rouN,-
Non-Water Supply Well: ft. R
❑Monitoring ❑Recovery fL ft.
Nection Well:
ft. ft
❑Aquifer Recharge ❑Groundwrater Remediation
19.6A ED/GP.AS'DL PAC 4(if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier mom TO mATERIAL EnfPLACartENTMil laOD
OAquiferTest ❑StormwaterDrainage ft. ft 1\
OExperimental Technology OSubsidence Control ft ft
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(I-Teatin)Cooling Return) 00ther(explain under d21 Remadrs) FRont TO DESCRIPTION color,bardness soii/roelr sae,etr
t!101L /11 B( Sc
4.Date Well(s)Completed--7-1 }� Well 1D# 0 7 . (jD ft• �S� ft ,tom �,2yi
5a.Well Location: Phone
eft it.
Facility/Owner 14ame T— Facility lD*(if applicable ft ft.
7 S3 l—tom fL ft'
Physical Address,City,and Zip M ft.
21.REMARKS
County h Parcd Ideatificalian No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(rfwell field,one lat/long is sufficient) 22.Certification:
3 � �3, l Ufa N 7 W
6.Is(are)the well(s):Aermanent or ❑Temporary Si of ed Well Contractor Date
signing this form,I hereby terrify that the well(s)was(were)constructed m accordance with
7.Is this a repair to an eidsting well: es or 8Noellic!',m e-V, ISANCAC 02C•0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well constructs information and explain the n.ue ofthe ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
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 OW-1 is needed, Indicate TOTAL NUMBER ofwells (add'See Over'in Remark Box).You may also attach additional pages ifnecessary
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths,ff different(example-3@2 0'and 2@100)
(e`t.� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10,Static water level below top of casing: r (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwaterlevel is above casing,use"+"
tp Bit Off: o�8® 24b.For Injection Wells:Copy to DWR;Underground Injection Control(IUC)
11.Borehole diameter: (m•) Program,1636 MSC,Raleigh,NC 27699-I636
12,Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wills:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producink over 100,000 GPD:Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test: 01 r
LJ` i
n DATE SITE VISITED:
13b.Disinfection type: 70/o HTH Amount '0Z
VISITED BY:
Form GW-1 North Carolina Department ofEnviroamental Quality-Division of WaterResources Revi416" d8
„n