GW1-2021-06298_Well Construction - GW1_20210915

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llC ° r•LOEI TO TiQWe Contractor � I
�` t l� C1�1
rr.0:� ft ft !�
NC Well Contractor Certification Number
p•���j gGt�
�CJ 15.OUTER CASING far multi-cased wells OR LINER if a plirable °
YADKIN WELL COMPANY,INC�j arL�� a�', FRo144 TO DiAa�TrR TSICrOIGsg TERUL
Company Name D. � �S�C �� , 7 kb ft. ft `�`�
t 16.DINER CASING OR TUBING(geothermal dosed-loo 0
Well Construction Permit#:13-70 f I? FRons TO DIA TER Tfficfavrss MATrtzrnr.
ist all applicable well construction permits(r a C,Crnmty,Slate,Vmtianc4 eta) ft ft. f j &in. �+
P3.Well Use(chectc Well one): ft. ft (` in.
Water Supply Well: 17.SCP,TZtI
Mord TO D1—'NKTZ7 I SLOT SIM I TffJ0GrES,- i.9-7iiS=_L
❑Agricultural DMM�u.nicipaUPublic ft. ft In.
❑Geotherm V eal(Heating/Cooling Supply) sidential Water Supply(single) it ft in.
�Q
❑Tndustrial/Commeroial ❑Residential Water Supply(shared) 1S.GF°OUF `-
DIrrigation ❑Wells>100,000 GPD lFroal To PUTEWAL EMPLACERr%NTRTRBOD C Ar..JOUNT
Non-Water Supply Well: ® it, y ' ft r r +
[]Monitoring ❑Recovery ft t ft
Nection Well: ut' JrK w
❑Aquifer Recharge ❑Groundwater Remcdiation ft. ft.
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SADD/GpAI'E1 PACK(if applicable
FRORf TO 7 MATERIAL I L71.4PLACLT+-MPTj 1%f jH0D
❑Aquifer Test ❑Stonnwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additionW sheets if necessary)
❑Geothermal geating/Cooling Return) ❑Other(explain under 421 Remadcs) FROM To NEXPLIPTION color,hardoess,sciVroctc sae,ete.
D ft. ® rr. 5;6 C.
4.Date Wells)Completed:
d: : I well rJ -62 ® fL - 0 ft.
Sa.WcU Location: Phone # S"�/_ 7 &'�-8'>So / 3(pa d
C;, -±v y l p nevi p.d
ft ft. ro
Facility/Owner Name Facility M#(if applicable) ft• ft.
/� �(.f�IQ Yi��• ft ft.
Physical Address,City.and Zip ft ft
Dar B e 21.REIMARTGS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwaU field°one lat/long is sufficient) 22.Certification:
S7 �Zi1 Ne�3-
6.Is(are)the well(s): ❑Permanent or ❑Temporary $,02f[re of(i5Xed Well Contractor Date
/ By sign6 g thisform,I hereby certify that the wells)was 15verq)constructed in accardemce with
7.Is this a repair to an existing well: ❑Yes or */qo ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill 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 an the bark of thisform. 23.Site diagram or additional well details: V 1
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 GW�is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: r 24.SUBAffITAL INSTRUCTIONS
9.Total well depth below land surface:_- A)
For multiple wells list all depths ifdifferw(ezample-34a?00'and2Q100�For this GW-1 within 30 days of well completion per the following
multiple
Static water level below top of casing: is s ( ) 24a. For All Wells: Original fbrm to Division of Water Resources (DWR),
Ifwater level it above casing,use"+" Information Processing Unit,1617 WC,Raleigh,NC 27699-1617
11.Borehole diameter: cy (in.) Bit Off: �•00� 24b.For Injection Wells:Copy to!DWR,Underground Injection Control(JuC)
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
(it.sage,rotary,cable direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing oyef 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: 8 Permito��.1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: 70%HTH Amount: /.J.7 OZ DATE SITE VISITED:e_'y-'�1q
VISITED BY: 096
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