GW1-2022-03390_Well Construction - GW1_20220315

Well Contractor Nam
� 5 �.� -72ft. 37� cSd .
_ fL ft. C
NC Well Contractor Certification Number IS.OUTER CASING for T!!1 used�rdls OR LII�IER if a Garble
YADKIN WELL COMPANY,INC. FROM TO DLUl7PTER TffiQIN6a5 TI RiAL
ft ft. i in.
Company Name
16.]P11VER CASING OR TUBING othermal dosed-loop)
2.Well Construction Permit4: FROM- TO DmmT= mucw s MATERIAL
List o/1 applicable well construction perm/ts r e WC,County State Yoriancq etaJ ! � ft. �1S in. 5DR 71 VL
3.Well Use(chectt well r,se): ft. ft. in.
Water Supply�4'eI!: 17.SCRE2N
rr.Ory TO DIAMEI—PR; SLOT SME THICKNESS I:l-tr.MAL
❑Agricultural ❑Municipal/Public ft. ft, in.
DGeothermal(Heating/Ccoling Supply) DResidentia]Wager Supply(single)
❑kdustriaUCommercial rsidential Water Supply(shared) IB.Gr.UUe
❑Irrigation ❑Wells>100,000 GPD Mon-1 TO I:aA,ERIa.L EMPLACEI:,IFJdT P.fEi60D C A-I-IOUN-f
N Non-Water Supply Well: U i1• Sftlair• t DU✓{�
❑Monitoring ❑Recovery fL 12
fL �7 S��n p l �
Injection Well:
ft
❑Aquifer Recharge ❑Groundwater Reediation m
❑Aquifer Storage and R ecovery ❑Salinity Bus 19.3AMIGRAi LL PACK(if alicbble)ier rrROnr TO MATERIAL KM.E-6.CdtMrr h=,t OD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
b. ❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if neema
❑Geothermal(FTeating/CoolingReturn) ❑Other(explain under#l21 Remarks) FROM TO DESCRIPTION color,Lardnm sanhadr type,gradn she,ett.
ft fL
S®� i
1 4.Date Well(s)Completed: V�- Well ID# �© J 3'6 ft- Voo Art Iwo
Q Sa.Well Location: Phone #3;rwl- ft. ft
47 Facility/Owner Name Facility ID#(if applicable) fL fL
J
/�O Gf�r/�d�l �a f t J�� ft ft _
Physical Address.City,an fL fLd Zip
el Zl•RRMdRKR
County ,( Parcel Identification No.(FIN) MAR 16
2021
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient) 22.Certification: 'r -�1 vr9
3 a5i il, 3 N I? �9, a-�99 W _ : 410,3P� fl N
a~. 6.Is(are)the weu(s):�6ermanent or ❑Temporary Signooff of Cext6red Well Contractor ! Date
N
a- By signbtg thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an eristing weU: ❑Yes or *Ro 15ANCAC 02C.0100 or 15A NCAC 02C.0200 1Yell Construction Standards and that a copy '
If this is a repair,fill out!mown well construction information and eVlaln the nature of the of this record has been provided to the well owner. N
repair under#21 remarks section or on the bark afthisform. '
_ 23.5ite diagram or additional well details: t
8.For Geoprobe/DPT or Closed-Loop Geothertrkal Wells having the same
You may use the back of this pageide additional well construction info
(`5
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofwells (add' to provide See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: [ C" / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 Submit this GW-1 within 30 days lof well completion per the following:
For multiple wells list all depths if different(example-3(a)200'and 2@100D
.Static water level below top of casing: S0 I ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10 " Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I10 Static
uvel is above casing,use
11.Borehole diameter: (in.) Bit Off: S• 9 7 24b.For Iniection Wells:Copy twDWR,Underground Injection Contra](IUC)
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
(i:e.mtge,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 DWI?,CCPCUA
13a.Yield(gpm) 3 0 Method of test: Permit Program,1611 MSC,Raleigh NC 27699-1611
4� ` i'
13b.Disinfection type: 70%HTH Amount: I� OZ DATE SITE VISITED: ,/�a `4 1'— ' - ( �4r
VISITED BY: (/