GW1-2022-00173_Well Construction - GW1_20221219

)C3LJ �1V51�YJCfi3aPIC®3�D {(sW-l) For lnternal Use Only:
I.Well Contractor lnformntion: -4
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Well Cantractor a PIIOM DBamn[TION
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NC Well Contractor Certi6eetiou Number li OUTER CASING formol&ned wells III a Rce a
A02 TO DUMIIRR TffiCdHIaa aIA1'anTAI.
YADKIN WELL COMPANY,INC.
R R in.
Company Name 16.INXM CASING OR TTIRING thermal chutd4m
2.Wen Construction Permit#: PROM TO riki inat T'�cm�ss MATBRMAL
List all applicable well construction permits(a U1C,Caunry,State,Variance,eta) 41 R R 10 e 1 1rm 30 R-o-( 1 flfc-
3.Well Use(check well use):
R R n
Water Su 17.SCREEN
PPh'well: Pnont 70 l)lAalri'iR S7.0T a77i THICKNESS b1ATgaa"
OAgricultmal DMJunicipaLTublic
OGeothermal(Heating/Cooling Supply) <Wcesidential Water Supply(single) R g. In.
Dlndustrial/COmmercial DResidential Water Supply(shared) 1S.GROUT
01crigation OWells>100,000 GPD FROM TO MATsmu1. I fi0ULC Mffi1TME'rROD A AMOUNT
Nan-Water Supply Well: Q h' 3 R &*C/�. pN/•!✓
OMoaitormg ORewvery ft 8�• R S„N .sly -
IDjecfioD Well:
R R
DAquifm Recharge DGroundwater Remediation
79.SAND/GRAVEL PACE da hle
OAquifer Storage and Recovery OSalinity Bawer FROM To 11ATESUAL ni Cn=Tmrmon
DAquilir Test OStormwater Drainage R R
DBxperimental Technology OSubsidence Control fL R
OGcotherma](Closed Loop) OTracer 20.DATLLING LOG atlach additionel sheep if necessary)
DGeothermal(HestinglCooling Saturn) ❑Other(exlain under#21 Remedcs) FROM To DPSCR3FMxee1ar bud m OW..ktype,enti,srsnete.
a
�j (er R M•R S. B.
4.Date Well(a)Completed: f l'- Z�-2-2,well D)# AAP-X 79 7o R /ooT R !i#" -$7r- 9/a'C
EL ft ,
Sa.Well Location: Phone #33G-(e' �-S�O.T
K I K e, 1-V n�- R fr.
Famlity/O Nrrwn�eme Facility M#Ciifepplicable) R ft
2n18 /4lnha Gi rtl e. Y A(#-AV OL �`' ft.
Physical Address, ,and Zip R ft.
Y"AIR►^ 21.xrMsauc
County Parcel Identification No.(MD
5b.Latitude and longitude In degrees/miautes/seconds or decimal degrees:
(if wen field,we tat/long is sufficient) 22.Certification:
OY .. 50.0n"N 90` Oe e73 .3C" W
6.Is(are)the well(s): ffilfrumnent or OTemporary Sire ofC ed Well Coabactor Date
Bysigningthisfarm,Thereby cero rhat the well(s)war(were)carutnucredin oecordmrae with
7.is this a repair to an existing well: DYes or fONo ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Consnudlm Mmrdards and that a copy
Ifthir is a repair,fdl out known well consnucrion information and erp/oin the nofwe ofthe of this record has been provided to the well owna.
repair under§21 remarks section or on the back ofthu 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 info -
construction,only IOW is needed Indicate TOTAL NUMBER of wells (add'See Over'in Ite,m a Box).You may also attach additional pages if necessary. _
drilled: 24.SUBMITTAL INSTRUCIIONS
9.Total well depth below land surface: /`�� 7 ( ) s
For multiple wells list all depths lfdfferent(cmmple-33@200 and2®10, R Submit this GW-1 within 30 days of well completion per the foltoming:
• 7 24a. For All Wells: Original fora to Division of Water Resources (DWR),
lf Static level below top of casing: !/� (ft-) Information Processing Unix 1617 MSC,Raleigh,NC 27699-1617
lfwa(er level l Is ubove coring,use"+"/'
11.Borehole diameter:�4 _(ice.) Bit off: S. 90']„ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Pmgrarn 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water SuDDly and 0De¢-LooD Geothermal Return Wells:Copy to the
(Lt.suger,rotary,cable,direct push,em.) wumy envimnmemal health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 10,000 GPD:Copy to DWR,CCPCUA
1 Permit Progra n 1611 MSC Ratei 27699-1611
13a.Yield(gpm) 1Z Method of test: ��n"�_ � M1t• (•_ µ�w���,rt*S rryy '�
a p DATE IIE VISI D: /a-I y-- 2-t- \�Q
136.Disinfection type: 70/o HTH Amount: �O OZ
VISRED BY: ���.