GW1--03423_Well Construction - GW1_20230516

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Well Contractor Name --•- �-._. Pr,'•:�i.lq � TO 1 -e®^_�-Ti_•il
2953 A ft fL .r
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a plicable
YADKIN WELL COMPANY,INC. FROM To DIAIl�TLR THICn7T1 ss 7ERiAI
f, I in. 25
Company Name 16.IN0Tt3R CASIIIG OR TUBING( -othermat dosed-loon) r1�
2.Well Construction Permitfl: FROM To InA.I=ER TH7QMSS tl4AT-M AL 1 t
List all applicable well construction permits rie.WC,Cormty,State,Variance,eta) ft. fi. � in. Z.� iQGcak She -�
s
3.Well Use(check wep use): fr, fr. in. �
r 17.SCRE P1
Water Suppl}`�irell: e�t.G6r TO D2?_T.•LT3? I SLOT SIZE I Tr C;?d3SC, I RIL:is:RIAL Fyn
❑Agicultural ❑Adunicipal/Public ft. fr. in. V
❑Geothermal(14eating/Cooling Supply) kResidential Water Supply(single) it. I ft in,
❑Indust-ial/Commercial ❑Residential Water Supply(shered) 13.GROUP ^
❑Irrigation ❑Wells>100,000 GPD I To HA TERr?L EM PLACEI:£+_47 PORTHOD c j&s:?oUlaT i.tv
Non-Water Supply Well: it• ft'
❑Monitoring ❑Rego,-ery ft �3 �e� p�, P����. _� b SJ
NecdonWei): 30 ft, Qaas6�6�®04 Paew�ft. �53
ft.
❑Aquifer Recharge ❑Groundwater Remediation n
❑Aquifer Storage and Recovery ❑salinity Barier i9.uAPlO/GPA?rL Pr�CI�(if ar,,°.icable)
IRon TO n4AT1 RIAL GMIPLt�uT:u�IT bTii�Ir oD
❑Aquifer Test ❑Stormwater Drainage ft. ft rn
❑Experimental Technology ❑Subsidence Control ft fL Z
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach edditioaal sheets if nerLsar sp)
❑Geothermal eatin Coolin Retum ❑OtheI FROM TO DLrSU]TTION color,hardness,sof fmck e, -n sae,eta
(H g/ g ) (explain under#21 Remarks) a ft '7S ft' P rt
4.Date Well(s)Completed: L�I u I a3 Well Em - 7 % 1d.®q ft. G ranal
Sa.well l48Eatri�f co�8l hone # 'KZfl 1723'3 fr' fL
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V t t ® .� °�®� �'lD fr. ft. �.• .t.- i ._�k •" ice' ,
Facility/Owner Name Facility ID#(ifappllcable) ft. ft. A V
fL
Physical Address,City,mid Zip �� ft. fL I nfof i; ^n '; ^:� ,,•;'� l�r;
� t l.-W Ci. 21.REA ARICC ss,,
County Parcel Identification No.(PINT) We"� ' &V4 U IM a+
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,mi.lat/Jongis sufficient) 22.Certification:
3(r A..IA" 3 N _73 NS W ►.,
6.Is(are)the well(s):,lbermanent or ❑Temporary Signat&re of ertified Well Contractor Date
By signing iNsform,I hereby certr;fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or /1No 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that s.copy
Ifthis is a repair,ftll out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
repair under#21 remarla section or on the back of thisform.
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 1 OW-1 Is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: C
�/ 24.SUBMITTAL INSTRUCTIONS �
9.Total well depth below land surface: ''.b�/ (f-) Submit this GW-1 within 30 days ofwell completion per the following: '
For multiple wells list all depthsifdifferent(example-3(a�00'and1ta3100) y p p
form to Division of Water Resources (DWR), -v�10.Static water Ieve]below top of casing: 24a. For All Wells: Original_ ® (n•)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" -
11.Borehole diameter: <p (in.) Bit Off: a",9Y7 24b.For Injection Wells:Copy to D N WR,Underground Injection Contra] (IUC)
AIR ROTARY
Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: 24c.For Water Supply L
and Open-L�nn Geothermal Return Wells:Copy to the [-
(i.e,auger,rotary,cable,direct push,etc.)
county environmental health departinei of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD• Copy to DWR,CCPCUA 2:,
t Permrt Program,1611 MSC,Raleigh,NC 27699-1611 G3 J
13a.Yield(gpm) Method of test: �d�
13b.Disinfection type: 70%HTH Amount: �� OZ DATE SITE VISITED: �o `-a
9� C
Form GW-1 I �2018
PRICE