GW1-2021-08128_Well Construction - GW1_20211109

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Well Contractor Name TO dtr_Y
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NC Well Contractor Certification Number r
15.OUTER CASIIYG for idulti-cased wells DR LINER,if a liUihle a
YADKIN WELL COMPANY,INC. rrtoni To D1AJltLrrElt TIDCMIMSs TERIAL
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Company Name g �
16.ROfER CrLgMIG OR TUBING g e othermal rlased-loop)
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2.Well Construction Permit#: �Q xROM To-.', MUCTER TffiC�QIIISS MA
List all applirable well construction permits(Le.LUC.County,Slate,Vatiance,'elcJ ft ft. in.
3.Well Use(check well use)
PVaterSupply'Wetl:_ 17.5C1tLZE 1 , �a
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ti:06t TO DYRiI'Tdt °LO�SI?C T3iGT]tES s It riPi�sl °
❑Agricultural ❑Municipal/Public ft. ftkrt , 32-
Irv,11
❑Geothermal(Heating/Cooling Supply) Jgesidential Water Supply(single) it gt in.i'
TSB
❑lndustrial/Conuneroial ❑Residential Water Supply(sh'sred)
ill,GROUT -
❑Irrigation ❑Wells>100,000GPD reoat To PtIATERt*.S RPtr r LACL PITtQs-T9 eDr 1:t oult Tt
Non-Water Supply Well: it. ft A -P 7
❑monitoring ❑Recovery
Infection Well: ft r, ik"3 Ka, titQyt
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❑Aquifer Recharge ❑Groundwater Remediatiomi• ft 1v c ,
19:SAPIg/G®Al'EL PACK(if a hro❑Aquifer Storage and Recovery ❑5 8linityBanier •FROar.,: To MATT UAL v LTIPEACeEl:ittlVT-::H=1 HOD.
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❑Aquifer Test ❑Stormwater Drainage ft ft. �
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer
20.DRILLING LOG(attach additional`sheets iilieressa t�"
❑Geothermal(11'eating/C001ing Return) 00ther(explain under 421 Remadcs) lrsonx To Mcltn'Tiorr eolor a_.~~r;nrroe�c" - Tote 1
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4.Date Well(s)Completed: y®'ei'� Well ID#
Sa.Well Location: N� f; .Phone # 10y�9��•Sy90 , fL
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Facility/OwaerName Facility1D#(if applicable) ft.
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Physical Addrrss,City,and Zip T— ft ft. I e
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Casty Parcel ldeutificatimNo.MN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: �r On���� -
(if well field,one laNlong is safficient) r
22.Certification:
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6.Is(are)the well(s) Permanent or ❑Temporary Stgaahae of Certified well Contractor{=spate
15 signing i02C. 10 hereby cite fy that the weu(sJ was j5vereJ co`ns[rueted of cccordance with 7.is this a repair to an eristing weD: es or L9No �e�'t(r ISA NC�1C 02C.0100 or 15A NCe4C 02C 0200 WeU Cdirstr'uc n Slandaidsmid,thot a copy
If this is a repair,fill out lmown well construction information and explain the natra a of the ofthis record has been provided io the well owner. ; t
repay under#21 remarks section or on the back of thisform. +�
23 Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this `Page to provide tiddmhomil"well conshvchon info ,
construction,only 1 GW 1 i�needed. Indicate TOTAL NUMBER of wells (add,'Sce Over,in Retails Box).You!may also`atlach sdditi�onal P�tf necessary, CR
drilled: 6
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24 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1003 3 (ft) i01
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following.
10.Static water Ievel below top of casing: 24a. For*All Wells: Original farm to DrvmsiAi0id W ater ]i
- (ft) Information Pmcessin Unit,1617 MSC,RJilet e
Ifwarer level is above casvig,use'4" g gh,IJC27699 1617
11.Borehole diameter: (in-) Bit Off: 57 t 24b.For 1niection Wells:Copy to DWR,Undtngrotmd Injection Control
AIR ROTARY Program,1636 MSC,Raleigh,NC 27699-I636 ,
12.Well construction method: 24c.For'Water Supply and Open-Loou Geothermal ReinirnaWella:Co . to
(i.e,auger,rotary,cable,direct push,etc.)
county environmental health department of the county whft instiWed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells Droducini over 100 000 GPD Copy to DWR;C
Permit Pro 1611 MSG;Ralw NC 27699-1611 13a.Yield(gpm) Method of test:�m 6 N �G C�
70%HTH 0Z DATE SITE VISITED
13b.Disinfection type: Amount:
aI[R.GCdd _ VISITED BY. ='k ��3
P�niGW_1 _- . . _ .".__ nental.Qoality-Division of WaterResaurces g� :�i�'•