GW1-2021-06794_Well Construction - GW1_20210809

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OEOrTHERMAL WELL CONSTRUCTION RECORD
, ,WELL CONSTRUCTION RECORD
yor Interact Use ONLY: $
This form can be used for single or multiple wells
L'Well Contractor Information:
�J►/� ` 1` 'Q, n� �'� 14.WATER ZONES I
FROM .TO DISCRUTIOri
Well Contractor N re V, � 7U17 ft. 320
`\\�� 6�Q, p� ft ft. ,
NC well Contractor Certificatiou Number Qv ��i �f� 15.OUTER CA IN for multi-eased wells OR LINER if a lice le
FROM TO DL414INR I rTmadi ss tt'1ATERIAL
Yadkin Well Company, Inca, rt, ft
Company Name IG.INNER CASING OR•TUB G tolbermal SIOSEd-10013)
�� /^�^O LrAS ����� FROM TO DIAMSIER 'TFIICKNM MATERIAL
2.Well ConstructionPer•mit4: Wx / n
Lfst all applicable well corismvction permits(i.e.County,State,Parlance,efe.)
it. ft.
3.Well Use(cbecic well use): 17.SCREEN
Water Supply Well: FROM TO DIAh1ETER SLOT SIZE THICIOYESS 1FIATIIRIAL
❑Agricultural OMrmicipal/Public
ft, M in.
❑Geotherma)(Heating/CoolingSupply) ❑Residential Water Supply(single) ft it
❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
❑Irri ation FROM TO MATERIAL EMPLACIIMENT METHOD&AMOUNT
Nou-Wattr Supply Well: ��n � �
_Benoilitp Pump
❑Monitoring ❑Recovery
ft. ft.
Injection Well: fL ft.
OAquiferRecharge OGroundwaterRemediation 19.SAND/GRAVE".PACK ifa l;cable
OAquifer Storage and Recovery ❑Salinity Barrier FR011f TO MATERIAL 1':fl TY—IcEMENi METHOD
ft ft.
OAquifer Test ❑Stonmvater Drainage
it ft.
❑Experimental Technology ❑Subsidence Control
10.DRILLINGLOG attachaddi8onalsbectsifnetessa '
eothermal(Closed Loop) ❑Tracer FROM' TO DESC;TI0,Nteior hardness sail/welt a ersin site,etc.
❑Geothermal(Heatin CoblingRehun 00lher(explain under 421 Rem arks n a iz 4.Date Well(s)Completed: S"!' '2, well ID#660' � �' Os-
& ft.
52.Well Location. Phone number n ft.
Facility/OwnerNanie Facility ID'I(if applicable) ft. ft
Win 4��od Lt.. rem 28' o-1 fI. ft.
Physical Address,City,and Zip 21.RE1NAR S
wAfQ-tAPl4; , s'v
Couuty Parcel Identification No.(PIN)
of loos er Bore 1• Dia. of too sue_
Sb.Latitude and Longitude in degrees/minutes/stconds or decimal degrees: 22,Certification:
(if well field,one latnoog is sufficient)
N W
Si aofC ad Well Contractor Date
6.Is(arc)the`vell(s): ❑Permanent of ❑Tttnporaty slgnfng this form,I hereby cert6 ihat the well(i)was(were)constnicted th accordance
w th JSA NCAC 02C.0100 or I5RNCAC 02C.0100 Well CoiistnrcHori Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of flits record has been provided to the well owner.
If this is a repair,fill out hiamii well constnrcflmt h formation and esplaiq the nahp•e ofthe
repair raider 01 remarks section or on the back of this form. 23.Site diagram or additional well details:
(� You may use the back of this page to provide additional well site details or well
S.Number of tivells constructed: T construction details. You may also attach additional pages if necessary.
For-multiple it jecrian or non ieater suppl r wells ONLYwfth the snare construction,you can
subrifr oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ �V (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa vnr/riple wells list all depths ifdie•ent(example-3 eQI00'mid 1©100) construction to the following:
10.Static water level below top ofcasing: (ft.) Division of Water Quip lity,Information Processing Unit'
If water level is above casfng,use"+/_ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bortbale diameter: Cf (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24'a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: $o Lary construction to the following:
(i.e.auger,rolaiy,cable,directpush,etc.)
Division of Wnter Quality,Underground Injection Control Program,
FOR WATER SUPPLYtiVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c•PorWatcr Supply&Injection Wells'"In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection Type: HTH Amount:. CUpS completion of well construction to the county health department of the county
where constricted. j
f
Forru OW-1 North Carolina Department ofEovironment end Natural Resources—Division of Water Quality Revised Jan.2013
Data Site Visii-•ed ! By: Q