GW1-2022-09486_Well Construction - GW1_20221014

t&iT�CNC��DN C®$Tp(G�-1) For Internal Use Only:
1.Well Contractor dnrormntion:
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NC Well Contractor Certification Number ]S.OUTERCASING for multi-need well da liable
YADKIN WELL COMPANY,INC. sROM io nusalEit a mATEaur.
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Campany Name /J 36.1HI✓$it CASING OR TUBING eothermo -
2.Well Construction Permit#: 7T�-��— �oM To »usecrmt s MAMEMAr.List all applicable well comdruclonpermits(t,a UIC,County,State,Yenlanm,etc) ft fLP�`3.Well Use(check well use):
1 37.Water Su 1 Well: FR SC[tEEN
PP Y mom To DunatEn slumr�aasss Maranul.❑Agicultural ❑MunicipallPublicft. ft. in•
❑Gcothermal(Heating/Cooling Supply) C Gsidmtial Water Supply(single) ft ft, �`❑Industrial/Commercisl ❑Residential Water Supply(Shand) I&GROUT.❑�( on ❑Wells>10000D GPD mom TO MATERIA Cr&1TMETBOD&AMOWallon-Water Supply Well: s • ftIVC/100❑Monitoring ❑Recovery ft aT ft +n-OurtFOAquibwr
ell: ft ftecharge ❑Groundwater Remediation 19.SAMRMAVEL PACK a linmetorage and Recovery ❑Salinity Barrier FROMTO MAxEDtALMPIAC-atd1CNT M�'1'80D r
est ❑Stormwater Drainage ft'®tal Technology ❑Subsidence Controlft ftal(Closed Loop) ❑Tracer 2D.DHILLINGLOGatbch.dditianal sheets ifneussa
FROM TO DHS�ON molar hudaea amVrvrk a've,etc
OGeothermel(Heating/Cooli¢gg R�etqum) ❑Other(explain undo 021 Remade) ft O R �. `
4.Date Well(s)Completed: ' V o Well ID# 0. a�10 ft -80' ft
sa.Well Location: Phone # q�l%10- 307 s eo ft �q " /Y►� "'T^ '�
- 7EQ 3O9S �19 ft �p ft to v n
k rt , ft ft Y-
Fa /Owner Name Facility n-A((iifapp//liiccable) / B �
'Z'7F�R' 61,fC T6 w .t JW Ww4 e P t4aCf L4 96 ft.
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Physinl Addvss,City,and zip �e,,nSt•5rrse asrt, 3 ft ft �,
he CC_ 2],RRMdRRR
Cow. Pam— t/ Parcel Ideati5catioh-N .(PUD
5b,Latitude and longitude in degrees/minuteaseeouds or decimal degrees:
(ifwe➢field,me lat/loag is sufficient) 22.Certification:
3(n .5'V©JP4c 1 N q1 U3512Q w
6,Is(are)the well(s): permanent or ❑Temporary S LMd..f0Kti1idWarCommom Date
By signing thisjbrm,l hereby arilty that thewell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orTo 15ANCAC 02C.0200 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
this it a repair,fdl out,known well construction viformation and erplabt the nature ofthe ofmhfs recard has been provided to the well owner.
1f
repair radar B21 remarks section or on the back ofthis form. 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 into
construction,only 1 GW-I is Vad. Indicate TOTAL NUMBER of wells (add See Over'in Remsrl,-s Box).You may also attach additional pages if accessary.
drilled: e^���, 10 74,SUBMUTAL INSTRUCTIONS
9.Total well depth below land surface: dy Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(fdfferent(esamp/e-3@200'and2®100)
(tW 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: I,fosmation Processing Unit,1617 MSC,Raleigh.NC 27699-1617
Ifwater level is above casing,use"� •"O
(in) Bit Off: Pro For 1636 S Role: Copy to DWR,Uadergrvurui Injection Control(IUC)
11.Borehole diameter: program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY county
yard de artsen-Lo,111111
nt Geothermal Return Wells:Copy tothe
(Le.auger,rotary,cable,direct posh,era.) county envimnmmto]health deparhneat t¢fhe emmTy where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells Producing over 100 000 GPD:Copy to DWR,CCPCUA
rY PmmH Program,1611 MSC,Raleig , C 27699-1611
13s.Yield(gpm) 1O Method of test: `f' IN�
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY: e�/Jgly
-__.., o r aroma ep vuonmental Quality-Division of Water Resources Revised"-201 a