GW1-2021-05325_Well Construction - GW1_20211013

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Well Contractor Name it. _p• t
NC Well Contractor CeRification Number
fit
RFis.OUTER CASING&ETmlti car veils OR LAVER if a ?cable
YADKIN WELL COMPANY,INC. r T cl 202� FROM To Durl+t>ccR TffiCIaVESs' MATERIAL
el ft. ft in.
Company Name �S�[1�U�`Z 16.INNER CASING OR TUBING("�I athermal closed-too757
'S.S'� FROM TO.. DIP.NII= TMCEWSS li7AT13i2iAL '
2.Well Construction Permit#: r r 9n ft
List all applicable well construction permits(r.e ourt� lance eta) - l I 1 D
3.Well Use(check well r.se): ft. & in•
l7:•Jtr"F'�F.LI l - g,z+�q �^V.�t I.F 'i73.�' X •fm �r
Water Supply Wei!: t Ors I To ni<ctETEa. sta,—stsc - .ru,c sliEsc� I1r,TsslurL'v�3_.•.
❑Agricultural ❑MunieipaOublie sa 3 L
❑Geothermal(Neating//Cooliag Supply) residential Water Supply(single) ff. fit. in
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01ndustrial/Conmtercial ❑Residential Water Supply(shared) Ip.GROUT ;;�_,z•- �
DIffigation ❑Wells>100,000 GPD Ft.onj To. rtrrTER1AL EMPLACEMENT
Non-Water Supply Well: ®: f �LL�
❑Monitoring ❑Recovery S_ �lNti�v
Insertion Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation IQ,SAT'ID/GPtll zt PaCrs(if a ,lieabley
❑Aquifer Storage and Recovery ❑Salinity Barrier MOM -To MATER AT: E FLAa-MV a - aOD .
❑Starmwater Drainage ft
❑Aquifer Testt �*
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG(attach additiodal sheeWif"iiexssa
❑Gth eoermal(14eating/Cooliag Return) ❑Other(explain under 421 Remarks) :FROaf To D2SCRIPTION eulur'bardn loutroetc
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4 Date Well(s)Completed: lh
Well 1D# o— U ft
Sa. &-Location: Phone # fit. t .54�
C4s ,
Farali / vmer Name ! Facility 1D#(if applicable) � D' 6 11 ; +
S,tzfI-et-em fit ft.
Physical Address,City,and Zip ft
ll 21.REMARKS f
`• eouoly Parcel Tdentification No.ON)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification':", 4
Y Y7 N
6.Is are the wells: ❑Permanent or ❑Tern ora Signature of Certified Well Contractor ? Date 7 i ,
is(arc O p rY � �
By signing thisfoi m,I hereby certify that the weU(sJ was(were)conshveled m accordmece with
v -a. saw: r,+nr.—
7.Is this a repair to an existing well: ❑Yes or 8No ISANCAC 02C.0100 or 15A NCAC 02C 0200 Well Construction Standards and that a.eapy
If this is a repair,fill out known well construction information and erplaim the mature of the of this record has beenptrovided to the wail owner.
repair under#21 remarks section or on the back of this form.
23.'Site diagram or additional well details:
tYrtronsl we mfo
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same may use the back of this page to provide ad ll cdnstruction
e (add'See Or'in Renutrks Box).You may also attach addihoiial
ye p if necessary.
construction,only 1 GTI is needed. Indicate TOTAL NUMBER of wells ..d
drilled: L 24.SUBMTITAL 1NS1RUC110NS
9.Total well depth below land surface: Submit this GR'-1 within 30 days of well completion+per the followwgp -�
For multiple wells list all depths if different(example-3@200•and 2@101D �t���. � 1
24a. For,All-'Wd`b: Original form to Division of W
( afer Resources+(DWR),
10.Static water level below top of casing: ft-) Infohnation Processing Unit 1617 MSC,Raleigh,NC 27699 1617 s
Ifwater level is above ca#ng.use"+ ;x/r
i Bit Off: S 9"• (!3 24b.For Injection Wells Copy to DWR,Underground Iajecti n Control(IUG�
11.Borehole diameter: rm) Program,1636 MSC,Raleigh,NC 27699-1636 W k
AIR ROTARY x � ,
12.Well construction,method: 24c.-Far Water Supply en and Op 'Loop Geothermal Copy to the
(i.e.auger,rotary,cable,erect 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,CCPCUAq 4<,�
Permit Program,1611 MSC Raleigh;NC 27699-1611 9 ,h
13a.Yield(gpm) I Method of test:
o q DATE SITE VISITED: > /iT �-cu
13b.Disinfection type: 70/o HTH Amount
.'sue
s A { s t
VISITED BY: • a - ,, ��
Form GW-1 North Carolina Department ofEnvuonmental Qdality-Drvision of Waterltesouraes Revised