GW1-2021-05578_Well Construction - GW1_20211013

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NC Well Contractor G°eRificationNumber tip 1 J \� 15.OUTER CASING formulti-rased'„wells OR LINER if a heable y.F
YADKIN WELL COMPANY,INC. FROM TO- Dreasrrsn_u 1'rnQWL+SS' ' MATERIAL �
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Company Name 111P 3 �� �G�"Or 16.INNER CASING OR TUBING(geothermal¢lased loo
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2.Well Construction Permit#: C&ISM l:r :S 1l " 2-0e fL TO D1Pn�i�R Tfficfa�ss 1�/+ ►L * '
Lis!a!1 applicable well construction pesnits(i a in ,Cmmty,5/ate,Ywiance,etc.) R' .�a m. Sj�/r f7✓T V� �
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3,Well Use(cheat well use):
17.SCPEZI:i I �}
®Pater SuppSy'Well: Mar., TO I Dl._ri'TE2 ELOYSra.Lt . I TkAH-WL50 T Pi TaPsr� r
oAgricultural ❑ unicipallPublic ft fL
❑Geothermal(Heating/Cooliug Supply) residential Watcr Supply(single) ;g ft.
•• S-y. -f, d90.
❑1ndustriaUCommercial OR esidential Water Supply(shared) 18.CnOUY.
❑Wells>100,000 GPD rsoni To r-taTLRLAL EN >nEi TLACN,METE10D C-AliOUNTJi
i7Irrigation .
Non-Water Supply Well: ft ,Psa-��Y S,
❑Monitoring ❑Recovery ILj
t Injection Well: ft ft h1 s
❑Aquifer Recharge ❑Groundwater Remediation ' rr
19.SAPD/G L PACK(if abri idable) -;:,—z.
❑Aquifer Storage and Recovery ❑Salinity Barrier FEODi TO NATL+tirAL .RUL U ANY iW,MOD:� g U
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❑Aquifer Test ❑Stormwater Drainage
4 ❑Experimental Technology ❑Subsidence Control JrtF'a
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attba additional sheets if neeessa
IrROnf TO MCP.1PTION Color haMAii`aorUruCic rams eR'
❑Geothermal(Ijeating/Cooling Return) ❑Other(explain under#21 Rema$cs) v ft• .Sa,Z
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k 4.Date Well(s)Completed:q f_ Well ID#�-/1z/ `s 2 —[ R' mo �� sfM.e-
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5a.WellLocation., Phone #` —A• V-O8--1® L s �` �
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Facility/Owner Name Facility ID#(if applicable) fL' EL
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Physical Address,City,and Zip
k k n REMARKS
h, Parcel Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22 Certi catlon•
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a ZCtJo TO I �� x .Y
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[[[ 6.Is(are)the well(s): ervraneat or ❑Temporary
Si of C ed Well tractor,;.
1 By signing thirform,I hereby certify th&the wells)Wass(were)constructed ui a�rdmicc wun?�
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S 7.Is this a repair to an erdAng well: ❑Yes or IRNo ISA NG4C 02C.0100 or ISANCAC 02C.02d0 iYe►1 Conilruchon Slmrdar sand that a Copy
If this is a repair,fdl out brown 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 thisform. 23.Site diagram or additional well details:
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8.For GeoprobrJDPT or Qosed-Loop Geothermal Wills having the same You may,use the back of this page to provide addttioiw well.construchnn-mfio
(add'See Over'in Remarlrs Box).You may also attach aridmonel pages tf necessary_
construction,only 1 G�V-1 is needed. Indicate TOTAL NUMBER of wells
s drilled: 24.SUBMLTTAL INSTRUCTIONS ;
9.Total well depth below land surface:® —(ft) Submit this GW-1 within 30 days of well completion per the following.. f
For maniple wells list all depths f&fferent(example-3@2601 and 2(a)100�
' 24a. For All Wells: Original form to Division.of Wader"k8ources
10.Static water level below top of casing: �® (�) Information Processing Unit.1617:MSC,Raleigh,NC 27699 1617 � w
Ifwater level is above casing,use
Bit Off'lu, p �s 24b.For Iniection Wells:Copy'to,DWR,Underground Injection Control(IUC) '
11.Borehole diameter: On-) program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop GeothermalRetnrn WeDsk Copy m the,'
(ic.auge,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed a hP'
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: 't� jeect,
70%HTH u oz DATE SITE VISITED:
13b.Disinfection type: Amount: �r 7
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1 VISITED BY: -
_ rsar_r North Caroline Department of Environmental Quality-Division of WaterResorvices Revised 0i8
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