GW1-2022-08848_Well Construction - GW1_20220912

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Well Contractor Name y -` -r- ,.E J TO^^ J I D _ aiC•ii
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells Olt LIIILR(if applicable)
YADKIN WELL COMPANY,INC. FROM TO DIAP:IETER THICICVESs AIATERTAL
ft. ft. in.
Company Name - i 1— 1
16.IIVIVER CA-SING OR T[1BWG Geothermal closed-loop) '
2.Well Construction Permit#: *3 6 1�-y'fey 0-0 FROM TO DD-METER Ta7CiCUSS MATU AL
List all applicable well construction permits(i.e.UIC,County,State,Yarioace,etc.) % f Q Q ft' (/ N in- S 0 Q'I 1P V
3.Well Use(chec`I well uxe): ft. ft. in.
St=.gplg�Ire19: 1i.SCI1•:.TT
Wafer
a,or.1 TO r:IETER SLOT SIZE TUK-Mi SS r:'Ii_TLr:L:1.
❑Agricultural ❑Municipal/Public fE. ft.
❑Geothermal(t-eatinglCooling Supply) effResidential Water Supply(single) et ft.
01ndustr-ial/Conimercial ❑Residential Water Supply(shared) 111 C-ROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO CIATERIAL ENIPLACEIrU:NT r.> T30Dr_-,Pl.IOUNT
Non-Water Supply Well: 0 3 ft. ote Pfe�o S
❑Monitoring []Recovery 3 fL » ft• QeMcjr COd Lf WSS
Infection Well:
ft ft.
❑Aquifer Recharge l7Groundwater Remediation
19-u"ASin•/G>v41Ct-L 1'ACIi:(ff applicable}
❑Aquifer Storage and Recovery ❑Salinity Bader -ROD. TO r.I.iTEtarsr EPIFLA nuisITd2•T Tr1OD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Iieating/CoolingRcturn) ❑Other(explain under#21 Remarks) PROM TO DESCRIPTION colon hardness,seit/rocictype, rain size,etc.
® ft. 90 -ft r a(
4.Date Well (es)Completed: T 1 Well ID# I®A 40 R• 3o3, ft 6 r& ., •
ft ft.
5a.Well Location: Phone #
_ ....
Facility/Owner Namf Facility ID#(if applicable) ft. ft.
3qyj ®lam &t 'Zgj,1 M ft. _
Physical Address,City,aad Zip J` J
21.REN RM9 U M I
County Parcel Identification No.(MD
✓S�.�•�ii t�c�J...
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
_" 13, 6//y N el 3!�eo96�6 w Wbb;�
6.Is(are)the well(s): Oermanent or ❑Temporary Sigaatt 'of C • ed Well Contractor Date
By signbig thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or No 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 infoTrllotion d explain the nature of the of this record has been provided to the well owner.
repair under P21 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also affach additional pages if necessary.
drilled: ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30i), (ft.) Submit this GW-1 within 30 da s of well completion per the following:
For multiple wells list all'depths ifdifferent(example-3Q200'and 2Q100D w y p p g:
�00 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level it above casing,use
f Static water level below fop of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter: � (in.)
Bit Off: (D 24b.For Injection Wells:Copy to DWR,Underground Injection Control (TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 O
13a.3Cield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Q
�S ���
c pZ DATE SITE VISITED: 2r-®��
13b.Disinfection type: 70/c HTH Amount: ® 14
VISITED BY: U IPS
e;a
Form GW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources '; m Be< sed G-6-2018
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