GW1-2021-02713_Well Construction - GW1_20210809

'Well Contactor Name 'rr:LwP.l TO' icIM-LuTIGii
/70
303C
NC Well Contractor Certification Number IS.OUTER G for multi-casodmelLs ORLIIdER if a 'tieable
YADKIN WELL COMPANY,INC. F1toH4 T DUNWE'R T Craanss TriRr�a,
ft.
Company Name 0 r�� C
U e� r l 6.II Cl4SING OR TUBING othermal dosed loo
2.Well Construction Permit#: 2 1`® WAI H ®� 4 81� To DIANiL�C�R T�rcxavltss nsAxesrai.
List all applicable well construction permits(.e.MC,County,State,Variance,eta) ( 1D`
3.Well Use(che&well t:.se); ft. ft ia,
17.SCI EZV
Watersepply'@ell:� " TOTSIZEf r2 T�ICr4+rS; ri�—sre:a
OAgricultural oMunicipaUPublic ft. '01R. lo•
❑Geothermal(Fieating/Cooling Supply) (residential grater Supply(single) tt
01ndustrial/Commescial OResidential Plater Supply(shared) M CIROUT
❑irrigation Meals>100,000 GPD repro To MA T&RUL HNPLACEILMNT P.MT9en c AMOUNT
Nor.-Water Sugp�ly Well:
� to .� : f� a`�te. .`
❑Monitoring oRecovery 3 ft d Js
ff
Injection Well.,
OAquifer Recharge DGroundweter Remediation
12.9At`IDIGR iv1~I.P C>S(ift 'cable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATURIA, MOSAMM47rviL"MOD
OAquifer Test L7StormwaterDrainage `
oExperimentai Technology []Subsidence Control
❑Geothermal(Closed Loop) [}Tracer x .DF.II.iJN,G LOG(aft'Mord
ch;ed�Iiosoaal she®ts f[ceress®.
❑Geothermal(Ifesting/CoolingReturl OOther(explain under#21 Remadm)___ To DgseAmrloN color a sonrra cer
fY Yt.
e
4.Bate WeA(s)Completed:2—2--IL—IL Well w#A"//pp i D- 603 Pt. i
aw4;J Pv-oi�ri s ft tt
5a.Well Location: Phone it *Q 7
ft #t
FacitityJOwneT Name e)Facility ID#(if applicabl ft R
yy
tr:.
$ l{
ft
Physical Address,City,and Zip
Gail v� �Y. r
Comity Parcel Identification No.(PII7) q'} F('teE•,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` k i b�ID ,
[dwell field,one latllong is sufficient) 22.Certification:
6a ° �
6.h(are)the well(s): Ciffmanent or OTemporary ignahne of Certified Wall.Contractor Data
_ Bysigningthtsforrn,l hereby certify that the well(k)war(were)consft ucted in acrardmoo wXh
7.Is this a repair to an misting well: OYes or M/0 15AMC 02C.0100 or ISA NCAC 02C.b209 Well Conslnrctias Standaids and.that a eapy
Ifthis is a repair,fill out known well construction information andesplabs the nature of the of this recardhas been provided to the well m mer.
repair under 921 remarld section or on the back 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 iub
construction,only l GE-1 is needed. Indicate TOTAL NUMBER.of wells (add See Over'in Remarks Box).You may also s#aeh additional pages ii'necessary.
drifted: 24.SUBMITTAL INSTRUCTIONS `
9.Total well depth below laird surface: 91Z (ftj Submit this G46'-1 within 30 days of we11 completion per the following;
wells list all depths ifd{ffereN(example-3@200'and2C3a 100)
Original 2(z) 4a, For All Wells: form Ito Di vision of Water Resources {DWR.J
10.Static water revel below top of casing: �0- �___!4,� lufarmation Processing Unit 1617 MSC,Raleigh,NC 27699-1611
Ifwwer level is above casing,use"+"
Bit Off: s 24b.For Infection Wells:Copy to MR,Underground Injection Control(TUC)
11.Borehole diameter: {in) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constractiott method: AIR ROTARY i
24c.For Water Suppl and nd Open-LaouiGeatherma!Retain Wells•Copy io the
(i.e.anger,rotary,cable,d"srect push,etc.) county environmental health department of the county wherc installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 SC,Ruler ;�e'D1CaE�,NC 27699=1611 g�C
13a.Yaeld(gpm) TO Method of test:,� �r � 18
a DATE SITE VISITED:
13b.1Disinfection type: 70/o HTF( Amount: d QZ
r �. VISITED BY: "� e