GW1-2021-00269_Well Construction - GW1_20211213

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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To D1AM�TER THICIOVESs TERIAL
ft. ft. in.
Company Name 11 S ,y 16.Il+INM CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 i/ oL 7 2 FROM To D14JVZETER I T1FQ4VEss I WATa_.arAt j
List all applicable well construclion permils(La.IIIC,County,Slate,Vadoncq eta) ®% ft. ft. in. 1
3.Well Use(check well t:se): ft. ft in. 4 6J
l7.SCREE2 I
Water Supply Well: Mord1 TO DIASIETM ELOT SIZE TtTiCF7di:Sr r:]=TiPi-L
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(1.leating/Cooliag Supply) #esidential Water Supply(single) it. ft. in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
❑Irrigation ❑Wells>100,000 GPD MON I TO AV-TEPIAEMPLACEMMNT Pj12-T9GD C AHOUNT
Non-Water Supply well: N. ft. T
❑Monitoring ❑Recovery ft ft
Injection Well: •^mil
ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAI iDIGR.AVEL PACE(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier F-POMr TO MA EPO -CE&LM-1 METHOD
® ❑Aquifer Test ❑Stnrmwater Drainage fr R
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
yV� ❑Geothermal(I`�eating/Cooling Return) - ❑Other(explain under#21 Remarks) FRON TO DESCRIPTION color bw-dnas soillrock a -n sae,etc
5-ft. /1 ft.
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V1 4.Date Well(s)Completed:, 3 a 1 well ID# ��tl l r R' ft
Sa.Well Location: Phone #fA gs ZCOt j J d R• ft
S 1J ou g' a 5 wLev ft ft.
Factitylowmer1kamc Facility ID#(if applicable) -77
ft ft. t
3SY }e�6 A/6l f3 ao� ft ft. nu 1' 3 202'
C Physical
�'Add'dressLLCity,and Zip ft ft
WQ'CW Gl. 21.REMARKS
County V Parcel Identification No.(FIN)
3 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
03�.Z N93�� w
6.Is(are)the well(s): Oermanent or ❑Temporary Signahae of Certified Well Contractor Date
By signing thisform,l hereby certify that the well(s)was(were)comoructed in accordance with
7.Is this a repair to an eidstin well: es or PJN � e 6/ 15A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a copy
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If this is a repair,fill out)mown well constructi information and apla the rf ojtht of Phis record has been provided to the well axmes
reparr under 021 remarks section or on the bark 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 1 GW=1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: L 0 24.SUBMITTAL INSTRUCTIONS •.
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9.Total well depth below land surface: ® (ft) Submit this GW-1 within 30 days of well completion per the following: N
For multiple wells list all depths if dii ferenl(example-3rr�r 20 'and 2(a)100) y P P g'
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) '-
lfwarer level tr above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 0 (ln•) Bit Off: e 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and OpenLLoop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 0 Method of test:
13b.Disinfection type: 70%HTH Amount: 1 OZ DATE SITE VISITED: Y7 7/to G �`
C e PO O 1 ____ VISITED BY: (/
Form GW-1 _ --vision of Water Resources Revised 6-6-2018