GW1-2021-03195_Well Construction - GW1_20210615

7or Liternll Use On,: - - - - --`
I ce.y c I .3 1 1 1-10-P yu -
1'3vrr1 TO Dry.,CF.�'+.TLnII
Well Contractor Name
ft. ft. I1 �
NC Well Contractor Certification Number 15.OUTER CA RLG for multi-cas`ed.w' OR LEVER if a plicable
YADKIN WELL COMPANY,INC. FROM, TO DIAAM TER THICIOVLsSS MATCRIAL
ft. ft ;in.
Company Name 16.RgNER CASING OR TUIIING(geothermal dosed-loop)
2.Well Construction hermit#: /O/l /L FROM TO DMAETER TMCIM-SS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft l0 in• t
ft. ft. in• l
3.Well Use(cheep well Use):
17.SCFET,i`d
Water Supply Well: FROM . TO WARILTER SLOT SIZE Ts3IC1ff9ESS HATERLAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothen-nal(Heating/Cooling Supply) residential Water Supply(single) fk ft. ini
❑Industrial/Conimercial ❑Residential Water Supply(shared) l0 OUT
❑Irrigation ❑Wells>I00,000 GPD FROM TO rgATrrRIAL EI:iFLACEr-NrIT r.-t='TroD a.tv.lourl
Non-Water Supply Well: v €t, ft. 14rV1 t?fetz
❑Monitoring ❑Recovery {,� ft. ft. "i rw ltN/r C. 1r
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAS1D/Gh'.A'1rEL 1'e1CIS.(if a liral'a9ej
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EP.•IPLr1C%IYa'"rrIT nmT'�OD
❑Aquifer Test ❑Stormwater Drainage ft• ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRELLING LOG attach additional sheets if necessa )
FROM TO DESCRIPTION-color,hardness,.soil/rocit e, ain size,etc
❑Geothermal(Heating/Coolingr _
Retu�]rn) ❑Other(explain under#121 Remarkes) ft.
4.Date Well(s)Completed: ✓ ` .0 Well ID# t�' �7 y� ft- Q/t�k
aIL
5a.Well Location: Phone # lc a 'v ft.
2:�8-723-:C13 , ft.
Facility/Owner Name Facility M#(if applicable)
ft. ft. s'
GdptA, �. Accf� RD ft 9
` ft.
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(MD
cessing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l
(ifwell field,one lat/long is sufficient) 22.Certification. n DVNR Secl"O�
3 17 ?4tSt l g _ a 80, S bY-s w
t�
6.Is(are)the well(s): �Ixermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1hereby certify thatahe wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IN0 15ANCAC 02C.0100 or 15ANCAC 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 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
s,
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: D -(ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3(a3200'and 2Q100)
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
Ifwater level is above casing,use"+" .Q
f 11.Borehole diameter (in) Bit Off: >6 0 0 24b.For Injection Wells:Copy to DWI C)
Underground Injection Control(IU
Program;1636 MSC,Raleigh,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 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) Method of test: QC V � ,
o DATE SITE VISITED: �4-1 _
13b.Disinfection type: 70/o HTH Amount: OZ QQ
` e VISITED BY; y `J
Form GW-1 � � North Carolina Department of Environmen -Division'of Watbr Resources i_,k Revised 6-6-2018 n