GW1-2021-03194_Well Construction - GW1_20210615

Internal Usft
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FROM TO DESC110VOil
Well Contractor Name W-ft. 12� ft.
,'? 5-9 2 -A 134 ft- 13C ft-
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased v(4fis)JORLMR 1fapplicable)
YADKIN WELL COMPANY,INC. oe THICICNE& MA FROM TO Di 11 TERIAL
ft. fr. f
in.
Company Name
16.LINER CASING OR TUBING(geother at closed-loop)
2.Well Construction Permit#: FROM TO DLAME-TER TMCJGqESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ®in-ft. 16�mv v-lrel
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: rptori TO DIANE= SLOT SlZrL TUYCTuIESS PIATEIMLAL
oAgricultural OMunicipal/Public ft. I ft. in.
DGeothermal(Heating/Cooling Supply) OResidentiall Water Supply(single) ft. ft.
olndustriaUCommercial DResidential Water Supply(shared) 11.GROUT
Vnigation DWells>100,000 GPD FBOA1 TO �.IATULTAL Et.,IPLACEr;-IENTP.,C-TEOD-Ik\l-.,IOTJIIIT
Non-Water Supply Well: Q ft. I?f,,4(A Jv' &I-e-'l
ElMonitoring DRecovery r
A-rr j,,eev(
Injection Well: fr. fr. I
DAquifer Recharge DGroundwater Remediation 19.SAHD/GP_!VEL PACLf(if applicable)
0Aquifer Storage and Recovery OSalinity Barrier FRONI TO MATERIAL ENIPLACEMENT HET HOD
OAquifer Test oStormwater Drainage ft. ft.
DExperimental Technology oSubsidence Control ft. fL
DGeothenrial(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
oGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION.PTION(color,hardness,sGil/rock type�grain six e�etc.)
- 0 ft. ft. Bit
4.Date Well(s)Completed: e w11 6 L4qfL S ft. J(ndv f d'
cj . . I -v 5a.Well Location: Phone 3 4151 <- ft ft e ki f Vi,&)e.-
Ar ft- 102 ft-
Fad'ility/Nner Name Facility M9(if applicable) ft. &
4 k �C
Physical Address,City,and Zip 11Lr4 N,
ij 21.REMARKS
CoAty, Parcel ldenti&ation No.(PIN) 5 202i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certificatioffifinrgat-1 n Pr6ressing Unit
3,(e I f ,6 N a-1 .1 F,, 1?'73 W s
V 6y)�VVFedon
'
6.Is(are)the well(s):'Vermanent or OTemporary Signature of Certified Well Contractor Date
By signing 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 tqo 15A NCAC 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 of this record has been provided to the well owner.
repair under#21 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 I GW-1 needed. Indicate TOTAL NUMBER of
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
is
drilled: I %, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 a -(ft') Submit this GW-1 within 30 days ofwell completion,per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
40 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
If water level is above casing,use"+"
Bit Offic 24b.For Injection Wells: Copy to'DWR,Underground Injection Control(rUC)
11.Borehole diameter: On-) Program,1636 MSC,Raleigh,NC 17699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigb,,NC 27699-1611
13a.Yield(gpm) 35- Method of test:
4
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
/ I ' i
41 to 4 W 4,(VSgED BY: �/
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North Carolina Department qJEnviqmn3,rji
Form OW-1vim' (W al, -Division ofWater Resources Revised 6-6-2018
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