GW1-2022-06631_Well Construction - GW1_20220711

WellCoutractorNaine FROM TO �C='YiOf!
ft-
ft ®� ft
NC Well Contractor Certification Number 15.OVMR CA-SING for 111ti-caffil wells R LINER if a P licable
YADKIN WELL COMPANY,INC. FROM TO DIAMWrFR THICIMss T6RIAL '
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: © '✓ FROM TO DIAMET
ER TffiCKMS MAl,RiAL
List all applicable well construd10n permits(i e.WC,County,State,lfal ianee,etc.) 41 It. ft. in.
in. �� "^
3.9ite11 Use(chec€ttseil use): l ft• ® ft• in. + ye .l {
li.SCc.�•ii 1 .
Water Supply Well: re_Oki I 7o I DiArJETER I SLOT SE-K TFTlCIGiRSG r:1:-TmP=-.L"
❑Agricultural ❑Municipal/Public ft. ft. in• J.
❑Geothermal(Heating/Ccoling Supply) Residential Water.Suppiy(single) ft U, in I
❑Tndtistrial/Commeroial ❑Residential Water Supply(shared), 11,C_RO J a
01nigation ❑Wells>100,006GPD ITON TO ,r.'IATLRUV_ EMPLACEAMNTM'M-9o:1)f.AJ-.-IOU,N7
Ngrr-Water Supply Well: ® it, ft.
01&nitoring. ORecovery f� t; a ( �1/�,// lYI
02
Fnsection Weil: t;..r ft. ft:
❑Aquifer Recharge =❑Groundwater Remediation '
19.SaStf3/GF.AlT,1,PACE:(r!applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FI'OM•i TO I MRIAUL L A crlrra_CR r+,,qT A.MTHOD
I7Aquifer Test: ❑Stonmvater Drainage ft. ft.
❑Experiraelitel:Teclin'otogy ❑Subsidence Control fL fL
❑Geothermal(Closed Loop). ';E)Tracef 20.DRILLING LOG(attach additional sheets if necessary)
FRORZ I TO DESCRIPTION color,badness soillroc n s'&ett
f7Geotfiermal.(lleating/CoolingRetum) •:'❑Other(explain under421 Remarks) ft s,c
t
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4.Date Weli(s)Cgmpleted:�� Well ID# " a t S' p ft �1
5a Well Location 1 lye
P17,01 e # 3,/>gVY,3���/ (^
DO
d ft.
41:�"�` �)� \.LJvli' JI j;•::
Facrlity/OvmerName _,,, Facility ID#Cif applicable) o ft ft S 1 rill � ,,�
ft fL
Physical Address,City,and Zip; `z+' A'YL ! pr.. .e,, _
f - - 21.RRMARRS 7
County, ParcelldentificationNo.t.04)
-
j ' ­5b.Latitude"arid Iorigitgdein,degrees/minutes/seconds or decimal degrees: 4 1`
^ ' (ifweIIfeld;-oad;law"Ofig is"'sitlficieet) 22.Certification• 1 r.
Signature of Certified Well Contractor 'Date
6.19(are)thewell(s) Rertanent or•'',❑Temporary
!. .:: By signing this form,I hereby certify that the well(s)was(were)constnxted in accordance with
7 Ls this a repair to an,elushI well ❑Xes or o
15ANCrIC 02C.0100 or 15�4 NCAC b2C.02U6^#1 h Construction Standards and that a copy
Ifths is a repair,f1!out brown well construcholi inforinati0n and rxplatn the nature of the of this record has been provided to the well owner.
Arepairuiiiler,#Il,teri�arlceseciioriororrthe6acicofihisform.
23.Site diagram or additional well details:
8 Far GeoprobelDPT or Closed-Loop GeothermaI Wells having the smme You may use the back of this page to provide additional well construction info
construahon,'only 11GW,•.1 is eeded. Indicate TOTALNUMBER of-wens See Over'in Remarks Box).You may also attach additional pages if necessary.
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24.SUBiY=AL INSTRUCTIONS
�f',,•. 9.Total well depth below land;surface: (fh) Submit this GW-1 within 30 days of well completion per the following:
For n uAiple wells llsi all depths if different(ezample-3@200'and 2Q10��
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levelF below tap of casing: 3� (ft) Information Processing Unit,16l 7 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
11:Borehole diameter: {in) Bit Off: . _ 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
{, Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction'iuethod: AIR ROTARY 24c.For Water Supply and Open Loop Geothermal Return Wells:Copy to the
(ie.auge,rotazy`cable,'d'iinct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:_Copy to DWR,CCPCUA
�! Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) J Method of test �f��
o DATE SITE VISITED: �
13b.Disinfection type: 70/o HTH Amount: OZ
VISITED BY: �f -
Z.._..rvv_r North CarolinaDeoartment ofHnviibnmental Ouality-Division of Water Resources Revised 6-6-2018