GW1-2022-01385_Well Construction - GW1_20220107

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NC Well Contractor Certification Number ®' ®�
15.OUTER CA-SING for multi-case Is OR LINER if a citable
YADKIN WELL COMPANY,INC. FROM TO DLAACTER T�crav IAI MATERIAL
Company Name t✓t• ft- I &AA m i 2 (9 1 t31 tit Oric
16.1NNM CASINO OR TUBING( othermal dosed-loon) L/
2.Well Construction Permit#: S ` �C FROM I To I D1AMu MP I TRTCTCNVss I MZA11MAT,
List all applicable well construction permits(re.WC,County,State,Ymiance,eta) l ft ft. i -r in. ,� / vc—
v
3.Well Use(check well use): ft. ft. in.
Water Supply'%fell: I;.aCFEsi l
FF?Ot.i TO DJAP:IsTER £LOTsrl.E T00,34E50 t:t*�iEPi?i
❑Agricultural OMunicipal/Public ft. ft, ire,
❑Geothermal(Heating/CoolingSirpply) residential Water Supply(single) it. ft.
❑1Idustrial/Commeroial [`❑_Fasidential Water Supply(shared) I&Gr.UUT
❑Irrigation ❑Wells>.100 000 GPD FROM TO MATERIAL EMPLACE W-ENT PIE MOD r AVOIINT
Non-Water Supply Well: vq '!n A' a e S tt✓C�
❑Monitoring ❑Recovery rl
ft 0 fG *, a /��,. f
Injection Well: ft. it
OAquifer Recharge ❑Groundwater Remediation
zi. 19.SAPID/GP.AVEL PA+CFi(if ap licablel
❑Aquifer Storage and Recovery ❑Salinity Barrier rMord TO M4ATFAUL LT.4PU.M.MT Hi T- OD
❑Aquifer Test SStormwater Drainage ft ft.
OExperimental Technology OSubsidence Control~" ft ft
❑Geothermal(Closed Loop) - ❑Trager. 1 :I 20.DRILLING LOG(attach additioad sheets if necena
FRORI TO DESCRIPTION color,bardnes soalroclr a grain ace,etc
❑Geothermal(Aeating/Cooling Retum) ❑Other'(explain under#21 Remada) t
�Aj ft
4.Date Well(�Completed: 2— 0-- I Well w AA o:'' I� ft w o,y
v 5a.Well Location: Phone #.33G-97 /
® ft ft'
S�—egg; i GIB,.4'G&4lr �4 01 -5G;I + iawidO
Facility/OwnezvName Facility ID#(if applicable) 24 ft' ran /
S. ;"..C ah .r-j - rs 1J "C� �"� ft ST n+, rJ 10� /G��a.�I .�s tFfr A(C
�. 'Physical Addres%. dZip a 3y ft. 6� It►'1 erg /Cn �p+9i1 e T i
County Parcel Identification No.(PIlq)
5b.Latitude and longitude in degreea/minutes/seconds or decimal degrees: JA Nr -
1" (if well field,one latllong is skied) 22.Certification:
3 C ZZ, 3.Lt3- N Yl 33,t6 f7
6.Is(are)the well(s): permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: OYes or ANo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Slandards and that a copy
If this is a repair,fill out Anown well construction information Ad explain the natrve of the of this record has been provided to the well owner.
repair tinder#21 remarla section or on the back ofthisform. 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 OW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: l 24.SUBAffTTA,INSTRUCTIONS J
9.Total well depth below land surface: e � ' (ft)
For ondtiple wells list all depths ifd�erenr(e=ple-3@200'and 2(� Submit this GW-1 within 30 days of well completion per the following:
1
10.Static water level below top of casing: t�` ( ) 24a. For All Wells: Original faun to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" f a Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (�) Bit Off: t�J 24b.For Injection Wells:Copy m DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.urge,rotary,cable,direct AIR ROTARY ect push,ex.) 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) 0 Method of test: yob G top
13b.Disinfection type: 70%HTH Amount: / U OZ DATE SITE VISITED:
A VISITED BY: •��o
e F.GW-1 S _ i vised 6-6-2018