GW1-2021-06428_Well Construction - GW1_20210915

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PEON TO
Well Contractor N e
S-fit. s' it.
01-577-A fL fL
TIC Well Contractor Certification Number 15.OUTER CA-SING for multi-cased wells OR LINER(if a licnble
YADKIN WELL COMPANY,INC. FROM TO DIAE�Tri TEacra E55 TERL4L
y ft. ft. in.
Company Name X 4.kw 3aG 3 2�®3 16.INNER,CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: 3 S FROM TO ft D> �R`a Tffic GMS MATERIAL -�
List all applicable well construction permits(i.e WC,County,State,Variance,etc) / � � S L
3.Well Use(checlt well use): ft. ft. in.
V.SCPLE2P 1
Prater Supply Well: i e Oti TO I DIAU.-MTcI I SLOT 517.E LTMCNNESS I TIA=LLLP1si
❑Agricultural ❑ unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it, ft. in.
❑Tndustrial/Commeroial ❑Residential Water Supply(shared) ia.GROUe'
❑Irrigation ❑Wells>100,000 GPD MOhl I TO MATERIAL EnULACEM-ENT I-Erm-SOD c.A&IOUNT
ft
Non-Water Supply Well: tl'
❑Monitoring ❑Recovery 3 fL ] t StLW
Injection Well: ft. ft IF
❑Aquifer Recharge ❑Groundwater Remediation 19.SAPED/GRAICL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATIZALA r. EP.P ELUMLAC rr METHOD \
❑Aquifer Test ❑Stormwater Drainage ft' ft' �/�
❑Experimental Technology ❑Su ft ft. vbsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additibnal sheets if necessary)
FROM TO DESCRIPTION color,hardness soiltrock 4 -n sae.ett-
❑Geothermal(Iieating/Cooling Rerun) ❑Other(explain under#21 Remarks) fL s-ft.
4.Date Well(s)Completed:o `Y-2' --- Well ED# A '��� �Qj - 6.g ft- p
5a.Well Location: Phone #3-TC-q�.�P��/3 v 1 fL klf(41 Imo' ICE }�
Facility/Owner Name Facility M#((f applicable) ft
J�
Physical Address,City.and zip & &
dC 46 KCP 1 21.REMARKS
Comity Parcel Identification No.(P114)
5b.Latitude and longitude in degrees/minutes/seconds 0r decimal degrees: �' �' J
(ifwell field,one Litllong is sufficient) 22.Certification:
�'Z Y-J N W249' 213
ry W � t
6.Is(are)the well(s): dermanent or ❑Temporary S�vtE"ofCeW edWellContractor, Date
/ BByy signing thisform,l hereby certify that the well(s),was(were) accordance)constructed in with
7.Is this a repair to an existing well: ❑Yes or do 15ANCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
Ifthis is a repair fd1 out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under 921 remarlor section or on the back of this form.
23.5ite 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 G�l is needed. Indicate TOTAL NUMBER cf wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
}} ��yy d
9.Total well depth below land surface: ® i (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if diiffari t(example-3@200'and 2@1001
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" {�
Bit Off: �� 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(TUC) I
11.Borehole diameter: On-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open I -Loop Geothermal Return Wells:Copy to the
(i.e,anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed N
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:_Copy to DVM CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /0® Method of test: Ari.c',®�veso (N%30
13b.Disinfection type: 70%HTH Amount: R�� Oz DATE SITE VISITED: 'Zf
VISITED BY: