GW1-2021-02395_Well Construction - GW1_20210722

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We]I Contractor Name
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RC Well Contractor Certification Number \JxJ 130ft. IS I -J,ok .23Jv 1
15.OUTER CASING(for multi-c9ed ells)O�L d2Eplicable)
YADKIN WELL COMPANY,INC. FROAS I TO D a=L 41
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Company Name ft
16.INNER CASING OR TUBING(ecothpzmal dosed-Ioonl
2.Well Construction Permit#: FROM To DIAMETER I Tinamss I mATrRTAT.
List all applicable well construction permits(Re.UIC,County,State,Variance,eta) +/IL J?3 fL t6��s I /Olve
3.Well Use(checlL well use): ft. ft. in.
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Water Supply Well: 17.5CPLEZN -TUTURE-1 L
DAgricultural DMunicipal/Public TMOT4 ft. To Aft SLOT SIZE_ THMG4ESG
ft.
DGeothermal(I'leatink/Cooling Supply) AResidential Water Supply(single)
01ndustrial/Commercial OResidential Water Supply(shared) 13.GROUT -------
OIrrigation OWells>100,000 GPD MON TO HATEMAL EMPLIACENTENT P42TEDD Ch ARIOU11T
Non-Water Supply Well: 0 ,,. --S ft. ";�k 3
DMonitoring DRecovery J IF
Injection Well: ft. fL ✓13-4;6,1Ae fJ-,.-z u 3
DAquifer Recharge OGroundwatrr Remediation ft. ft.
OAquifer Storage and Recovery 19.SAND/G-RAICu L PACK fif aprilicable)
OSalinity Barrier FROD.11 TO MATERIAL I EN1PLA-CLT.M41 DOTHOD
OAquifer Test 0stoirawatrr Drainage ft. ±1- !t�
OExperimental Techn6logy OSubsidence Control ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necesSU31)
DGeothermal(14eatingICooling Return) 00ther(explain tinder#21 Remarks) FROM TO DESCRIPTION(color,bardness,sail/rock type,grain sizz,ern
0 & f/
C-.jg-21 wd,,D#,A -1,6q .r t.
4.Date Wells)Completed: 40 alpft - + -14k,
Sa.Well Location: Phone # J?10 62 f"
t ft. ft.
Facility/Ow=Name Facility Nrif6W livable y' ft• ft.
t ft. ft.
fT I ve-ef
Physical Address,City,and Zip ft. fL
2L REMARKSLd-A! a,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Ccrtificatio
0 W .5;w
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6.Is(are)the well(s): Permanent or OTemporary Signature of Certified Well Contractor Date
Bysigning this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to in existing well: OYes or mo 15ANCACO2C.0100or15ANCACO2C.0200 Well Construction Standards and that a co
If this is a repair,fill out known well construction information dnd explain the nature of the of this record has been provided to the well owner. copy
repair under#21 remarks section or on the back. ofthisform. 23.Site diagram or additional wellLdetails:
8.For Geoproba/D.PT 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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You'may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth be low land surface: '-�� Z
For multiple wells list all depths ifdIfferent(example-3@200'and 2@100) (ft) Submit this GW-1 within 30 days dwell completion per the following:
10.Static water level below top of casing: TO (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use 111. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: Bit Off:14 a.' s 24b.For Injection Wells:Copy to DWR,Underground Injection Control(rUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constructionmethod: AIR ROTARY 24c.For Water Supply and Op n-L I oo'p Geothermal Return
(je.auger;rotary,cable,d�sect push,etc.) countyWells:Copy to the
environmental health department of county where installed
d
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,060 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 o Method of test: 'q
13b.Disinfection type: 70%HTH Amount: Li Oz DATE SITE VISITED: :�--IS-4/
VISITED BY:
Form&W-1 North Carolina Department of Environmental Quality-Division of Water Resources
t Revised 6-6-2018
PRICE ; I i ell 'i- A