WI0100414_Geothermal Well Construction Record (GW1)_20160209

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1. well cams=rorlafmmanan: r I MAR 1 4
wd cf
�.towm'Ny,e
C
ry J.%� g
r7 '1I
Water 011.1h Rnaicnal
Asheville Rpniol,n
NC Well Cantracmr CeniSadwNumher
""'--' - --�
Yadkin Well Company,
Inc.
Companyll a
2. well canabvc0an Permit,.: gtot01 OD i2/$�
¢moll aPPuener, n•,urnrr,rnrcrmnPe„nrr, P.e. cnmry, arms v rfmra,.m.)
3. w=n Haa (moor wen use):
OAgricaltwal OMuniclpal/Public
❑Gmthermel(HeatinglCooling Supply) OResidential Water Supply(single)
OlndustoWIc..nn,. l OResldeemd Water Supply (sh-ad)
OAquife Pecharge
OGroundwater Remedietion
QAqui£er Storage and Aecavuy
o9aimityDanicr
OAquifer Tert
O9rormwa[erDminege
pl3xperimentel Technalegy
OSubeidcnce Control
O,eathxrmel(Clms dLoop)
uneeer
4. Dafewell(s) CnmPl lied: Well w# A/4t4` 2r+�
sa. w//enLa=atiaa: Phone number
PawlitylOwnerNanm Fwility ID.i (ifepplica6le)
267 Rack sn✓iny f2a 61,11 O,-&4
Physled Adkeu, City, and Zip
%folk P 78—I
Cauory - PundldentificadanNe.(FIN)
Sb. L2 mode and Longitude in degrees n inu(eaheccnds 01 dezimal d,,ees.
(ifivell field, we hO... le aaffident)
3s- 22, 22/S' N $2 ` o s
6. Zs (are)thewell(s): L9Pe,rvanenY ar OTempor.oy
7. I, tlds . repair to no, existing Well: Oyes ar Wile
11rnf,{,nrapm..frmafdrennwdiron,m�crrtn iNr lmnnrrde.�rrtrq lnennlm. fine
r Dnlr mrdok31 rzniarbeecrtmr moa zhebrtek afrMafomr.
9. Number ofWells cevstruaed: I O
Fm' mdalple ej afon oraromvafersiipPlyn'gills OlrZl',vldJlrerrtnreewrzhne!{oq... cmr
...b'Oenef'n,
R
# of loops per Bore ( I ) Dia of loops `
22. CertiSmkon:
✓%�%��a-2%-.�01
sibn.�n ce,etsnd, {nllcnnuaaer, nafn
by�dds form, I M1eredy cerOfy tlmr Ore coal((✓) rvee (rvnvJ nomrnmtMm oaordmme
+onh 1 SA NCAC 0]C.0100 mfSANCAC @C.@00 Well Cmrsmemion SrmrdmHs and rhm n
ropy jrfils record Irns deeu prnvlded ro tl¢ mall comer.
23. Sife diagram or additionalWelldetails:
You may useihe back of Nis page to provide additional well site details or svxll
constmetion details. You may abaoettaclradditionel pages yfnecessary.
9. Totahvell depth helmvland surface: L S.S� (ftJ 24n. For All wells: Sb,nit this farm Within 30 days of completion of well
Fmvmdnplervellllel all deplfu fjd�,renf(em,p(e-9QIo0'm,d3©I00'J CanSfine[iartto Ne folowing:
10. Stnticwater level b=lmv tap of n.11 a
Ilnnrerlevelf, ndaw rc,mq, „se ^r•
31.Harebote diameter: (inJ
12wellcoashmdltllnetbad: Rotary
n; 1617 .11SeuIi. City,I md1i ttoaprocessing17
1617 Mail9ervim Center, Raleigb, NC 2]699-1617
above, elso s ¢fait wells In tide
to ithin3Nefarm tocn lettion f 11
above, nti. s.me a copy of Nis {orm within 30 d �s d'eompleti�n aF well
conatmctionta me following:
(i.e. augz,, smug cable, dvec{push,eR) Division of Water Quali b,, Underground Igjedion Control Program,
FFORATER SUPPLY WELLS ONLY: 1636 M.Il S,nvlce Center, RatigL, NC 27699-1636
ld m Method oftest: .PidditiontosxncIllthemsmto
(gP )— Nddbe,., also submit ova copy of tills form within 30 days of
Cll 5 com,kii.. of well constnmtian to the emmty health department of the county
j festiev Type: HTH Amount P Where eonstmmod.
From OW-1 Nodh Cazalina➢epytment afPwhomoent a mtenlllesowcee-DNIi!-efWeter Quality IdQ �p� �l1(eviaxd]w.2013
Data Site visitee: J,0„1f BY: bo

QE0JHRRMAL VVELL
D
MAR 1 4 201
25'V, Wain Gr ultll N li md101
NO WeIl Contreotor CeNSaatiou Norte, 11YItF 1 'r+CI�
Yadkin Well Company, Inc.
Company N.wc
z. WAlconshuclim Pn'mitg: lv.lOi ao Y'/4
Llrf onapynenal. rvebxornn,+cnmr p,+rra„ sc,' Pm(mmq. r)
3. W dl Use (,hell, well use):
OAgricultural emaudcipal/Public
oGeoelecura)(Reating/Cooling Supply) DResidantial Water supply(single)
frralaslriellComnarcial OResidanlial Water Supply (shared)
GAquifer Recharge
OGroundwater Remediation
OAquber Storage and Recovery
OSefmityHarrier
OAgaif.,Test
OSnumeat,,Dminege
ORxperimental Technology
OSWaidenca Cantm`l
dl`ieothermal(Cldsed Loop)
GTmcar
4. Datcwell(s)Completed: �ib warms AS NL- 25,�[
sa. walLa,alan: Phone number
Feeitiry/OrvaerNanm Faeiliry ID#(SappGeahleJ
zs Rank ,� y 2a �G&Malt
Physal Adkss0wdLp
i0/
P
County Pmxel idendpvationNa. (PM)
56. Laltude end Longitude is degree/minutes/seconds ar decimal degrees:
(ifrveli acid, one lemongis aulinunQ
3S- 21., a.2_/q� N R2" o8
6.Is(m'e)thr..11(s): MKrnr. ant or OTempmary
7.Is this arepair to Rn exfsiingovell: OYea ar 16.
pJddr or nIa efullonehmvnrr•ellcoolueakr h"rmoRmr midaokh, th"cor cf1he
ryvinnrderkll.nnmbmalauarmr'ha beck,"Inr/(r— /
8.NDmbar'afwellaenuntreted: 2 .l b -
For cedriple Olenrmr oiaronnvalereiipplyr•alb ONMOA fherr-ar MneliorSYauron
>abranoaaft-
9. Total well depth balmy land aurfece: 285- (ft)
FIN'nmlrrple leell>an ell depar, tfaye+ma (execpie- 3@200' mud2(a100)
10.Stalcwatmlevel belmv top of easing! (ft)
lfm"rhvd Rebove-6,, n>e •'+-
11. Borehole diameter^ (in.)
12. Well covstruc(lon method: Ito armor
(i,e. ata, mmg cool% dlrectpuGI, etc.)
FOR WATER SUPPLY WILLS ONLY: '
13n. Yiela(gpm) 1% Method cftest: 24c.F W['S f&Tftl wll')RadditiontdaendtogtInformto
The addfeas(es) above, eifio submit ona copy of this farm within 30 days of
13L Dislnf ,SIN HTH Amount: CDpS rampla60a of well ematmetien to the county health department of the county
tyP`' where rem,hreted.
Foinitemoi UPeONLY:
Id. WAgBRZ
NE6
P&OM
'IO
DFS L1llPT10N
6rflYl;` iG
(L
13.CllTER
CA IN far mulh ansnlnells OA
LLYER i(a 4m le
PAOM
TO RLMfPTER
TWCIGrE33 fAiERUL
re
V. m.
16. INNER
CASING OR. TUB NO ev tbermal dosed-lvo
rnoM
70 nrM1ETaR tnlLlaY%s
M morz .
rc
fL iv.
IZ SCREEN
IR09I t0
➢IAhICTGR
6LOT BIZR
iWCf4Y469
IA'r01llAL
re. n.
rt R.
m.
N-GROR"
-MI
FRO
x0
I nrAT 4t
En1PLAC6M Tod6T¢ODmARta
q
rt.
tt.
sG
R.
19. sAND/GRAV➢LPACRfifa
liable
'
6ROM
TO
lrL4iCmdL
Lh@IACZM¢NTMSTHOD
fe
R.
fe,
ff.
1d.➢RILLIIVGLOG
vttadavddlNoualaheeb
itaumv,
PROM'
SO
DLSCn1PRONReIer'.M1mtlness veil/ndr riln she et
vi' rt
A{ rL
�Ar SC+,L
IIQC4C Z✓t.
R.
ft.
a
tt.
R.
MAR X 7 mu
ll. AEhIgRSiS
21 w rh.0 Flfr:-',"n Vnh
of loos er Hore ' Dia. of loos -
22. CCartlleauff.D:
�!.e eNSed Well Con4actar, Date
AY elg+r6rg rM1U famr, IOere6y nrtt/j• tlmrtfie mallO mw dnere) mntlnmfed ve vcrordmme
>vlrM1 IFANCAC OIC.0100 or IPANCAC OIC.OI00 tY IlCmnmmdmr srmrdm'ds and rM1m n
copy I#tl. rerorAhm6emprw/dadm+hewell none,
23. Site diagram re additio➢aleveil details:
You may nee the baal, n£lri4 page to provide additional wet site details m oval
cormaction details. You m yal¢R attach additional page jfnecessary.
SUBMITTAL DYSTUCTIONS
14n. For All Wells: Submit this form within 30 days of completion of well
constmction to the following:
DivisioD of WnterQunlity, Infarmntiau Pracessi➢g IInlf,
I61] MnilSmvitt Ce➢ter, Rnlelgh,NC 2]699-1617
14b. Far Iu'eetbn Wells: ID additianto sending L,e form to the adda¢s iv 24s
above, elm 6nbmit a copy of this forth within 3S daya of completion of well
canstmctionto the following:
Division of Water Quality, Underground Injection Unruh al Program,
1636 Mnit 8,Mn Center, Raleigh, NC 27699-1636
F.aw-I Nedh Cuoli RDUp entatEmhmaosntmd NalmalRu =es-DivisimofWaterQua ty rxrlSV /.oyri U$evisedlm.10t3
a' " Date site visii-ed: 1-13-/J Hy:: bO .rt.

c,EC)J ERMAL VVELL
'r.xxaylC xKC. YYA(Yx > ForL,o
Ths fwmcanhe usW fvvsingle ormvitip(eweVr
1.Wallco.itme.eld nation: MAR 1 4 2016
..Sey�r f.t� M.trll tS MAR 1 d on f4.ry
WaterOn itv Rcti:onel Opt
957a-.¢
NC Well Contradw Certification Runde,
Yadkin Well Company, Inc.
Coa➢any Noma
2. Well CamhncNonPerMtk: wTc 0
6 ¢)y*
Ltcl rail ap(Icnb(nxd(m,n/nrcnenparutl/s tr.e. CorniY• 5' Yorleneq elnJ
3. Wdl Use (cbecIInrzll use):
rz.
0Agricultural oMonicipal/publin
❑Geotbemmj (HeatinglCooliog Supply) OResideatial Water Supply(single)
olvdustrial/Commemisl oRe,idacu Watar lufplylaharad)
ofrri od"
r°
ft.
re
ft
1e. CROLII
PROM
p
Nau-Water Supply Well:
omartorivg Me ... any
6
ft.
Inje[tiov Well:
❑AquiA,Recharga OGmundwater Remadiation
OAquifer Storage and Recovery o5almityBarrier
OAquifer Twt oSmrmwaterDreioage
OExpcdcarr,al Tevbnvlogy oSubsidmee Control
Vaeticermai(rinsed Loop) OTmcer - _
ft
f..
19. SAMIQrAWLPAC
.ranger
I xo
R.
ID
m
sa Mmu
mc^oc aro
43434
4. Date}yeil(s)Complefed: a� I` Wet1IDp /C}/�/r'�� 2.%,�
re
rtfeY^'
6a. W lD.oratien: Phone number
R.
in
cfkaa-te,f re d,
rt.
rr.
in
n.
T
£-,dVev —vName Fa[iliryID#(ifapplieable)
ft
e -,.
EIVED
2C 7 R<ck .t ,:ray , fLa Mili�.f' i/.t
R,
,tt..
Physical AdL ss, City, and Zip
ft.
fa
�D {� �—(
11. REhL4RP5
—i
Couury RmcelIdend6cade.wn(PIN)
I rK50C, foc'65S Unh
of lags er Bore DbU isof
log -
6litudeand Longs idegrcos/mWutmGecvnds or decimal degr'eeso
22. Certification:
(iRvewall D field, one lallovgis sufEaffi=ien[)
3S- 223
ZZ, N 8a' O $ r (95CD
/
G.Is (are)thewell(s): �Permnvent or oTemporaay
�An tore p[C iLSed WellCorJncrar pets
BY alemrGig Rri+Jme 11,v[by arlpl,he, do"[I(,)ear (Ivan) cermmcledM ecc",a'c
11
7.Is thlsarepairio an existing well: pYas Orfu1Vg
IIIA15ANCAC UIC.0100 or15ANCAC O)C.O]00 Nell Cmramattmr SYmrdmats and lM1m n
copy jdR rermdnas 6enrprovfdedro aneweli comer. .
llrnlr/adr p/,e:Nnemm,a+, watt[mmnrcrsr,nymrn and�rnlp ma,rnnns Jrda
r yoi,corder@L anmaFr,.amm,a mrtne bvekoldtaJa�n.
23.Sife diagram or addidovahvell details: '
3
You may e the back of dash page to provide additional wet site details m well
meegnshuction
S. Numbmvfvvdls eonahvcfed; D�
details. You may also attach additional pages (inecessary.
Fm'mulnpla injeonmrm'nen+ro/nvuPPY weIW ONLYrvI/h
lm emue [onr
the¢liog yomm�
sn,amn onel rm.
SUBMITTAL INSNCTIDNS
n.
9. To blwall depth belmv land surface: 2 gs� (ft.)
24n. F All W 11 : Submit this farm within 30 days of completion of well
Fen—doPlewNG!lrlall Qom, pebbran (enradao 3Q]00' ae"i@IGo')
oomtmetied to the following:
10.St.Hervater level helmv tap of easldg: (ft.)
Division of Water Qunli(y, Information Pa'ocessiag IInif,
5lwoeealevettr obov. amb, vae ^+"
1617 Mail9ervica Center,Ralcigly NC 27699-1617
11.Roreholedlameterr (in.)
24b. gor lviec:ionWll: hadd@ion to sending the £orm to the address in 24n
12. Well construction me Wad:_ otary
above, also submit a copy of this form within 30 days of completion of well
eoeatmeths, to the following:
((e. augers nary, cahk,diren,puau, etv.)
Division of Water Quality, Underground Igjeefion Cgnhol Program,
1636 Mail Suvice Center, Raleigh, NC 27699-1636
WATER SUPPLY WELIS ONLY:
Yleld(gpre)_ Methodoftest:
F
24aF W t 5 i El infl 4V11 i addithmtgsendingfheformto
the address(w) above, also Submit one copy of this form within 30 days of
Disinfection type: HTH Amnuab CI I
completion of Well construction to the county health depedmant of the ccamy
where cgnstnoted. ,
£mm OW-1 Death Carmine DVarmaent o[Pwimauoerat add Natural Ratener-Division ofWeta Quality �`app
Data Site Vi si 1-ad' I„a,�f By:
b� awjdoa Lapp UI(avisedfm.20D
3 �,,.• _. _d. J

6EOjHERMAL W0-L
VWllrJLJL 4:Ur1VSILC(U4;IlIl4p1V I'Q:QD1K99 - .. peiLnemSl Useomy.
ills krnmmbemed 6rsin%lecrmddpleweps {
1. Well eonnaerorld'nrmat;M1n: MAR 1 A 2016 _�_ -- 4.2434z
Water (]uality Hn,lOnil ODOI
,9S7a4 _nGl ryrr I _ �r n qnw
NC Well Culn.o r CerEfi a.d aNumber
Yadkin Well Company Inc ie In
Cvmperry Nana 16.➢ It CASING ORTn G mlbermald—d-Im
1 a PROM RO ➢LNe%rER Mrs...,
2. Wen Comhnctian P"mit%: w V ll 9. 1, n. r
LLrnll"I"blevenemnn,rcrlmrparurrv(le. Con ,,seem urlo'da.) 'v.
n, in.
3. Wd1Nse (rLcrinvdl use): rv.1 —nu
OAgricultuml OMunicipal/Publio
❑Geothemea)(HeatinglCooling Supply) OResidantial Watersupply(single)
OIndustrisl/Commevcial ORcsidential Waterftdy(ahaad) 19. cROVS
PROM1I ZO
Pim.- atlnn 1p�R. Q. R.
Nou-Hater Supply Wdt W
OMonitming ORccovery R f"
OAquiitr Rechsroe
OGrenndwater Remediation
I FI3.SAN➢/GMV
PAC
DAgoifer Storag and Recovery
09alLity Barde,
anoM
To
re
R.
OAquifer Test
OStomos,ed"Dodrage
oExperimemfal Teolunde,
OSubsidevice Control
Oeothumal(C10'sed Loop)
OTrncer
p0.➢NI.LINGLOG
r:e
snonr
o
4.DuFW,D(s)Compiehd:24A wenmo AAM— Z3-
5a.Welll.neatioa: Phone number
�•�i, a,rle,.3' �erdon
FaaJiry/OwacrNenw FacJity ID%(dapplinable)
2C7 R=Gle Jn ; rta M;d/s.,tiA
Physical AdLvse, n'ty, and Lp
Palk P 78-1
County Famell&rU6caSnnNv.(KN)
So. Latitude and Longitude in degrees/mmntes/seeands or decimal degrees:
(1wen5eld.onefamoneissuffIcient)
.3S' 22., 2-2-
//9. N 80 ` O g . 67L N
d.Is (are)ILe wdl(s): t9Permnuent or OTempmary
7. Is tLh a repair to an Aalfngwell: OYcs or 1r31Go
]JRrG irrnapn0:fl11 autbroxarwell evna(nmOmrFJ rmotivn turde ylaiq rbe ... lhe
rynir corder 921re...to—don. rA<bnek(v[fILRfQomr.
B. Numbao£weils eonshvcted: /-�7 6
Fnr,mdttPle IrJee!/vn crayon-nabreirpPlYweIG aNLAvriFfiermnv emrstrra(/m5 yor¢an
mrbnrtt om)orm. n .
9.Tot.l,l,Udepthbelmv land surface: 2 SSA (ff.J
FinamdlPlnvellr [Bfv![dPlFx fJd�renf( vnQle-3Q100'mWIQi00'J
10. SmIle.icrlevel hdo"Upotcaafug: (ft)
II.Borehele diameter: Qu.)
12. Well eoushvcfion method: if Ohar V
S.e augegmlarg cable, dhed,pasir, etc.)
FOR WATER SUPPLY WELLS ONLY: -
13e.Yield (gpm) 0 Method Oftest:
13b.Disinfeetiontype: HTH Amonvh CUPS
to it.
to. fL
it
21. REhfARN6
Pored Depth 296' DWQIBCIG
of loos er Bore llia. of loos `
22. Certisl.lims
dace£ 'fled Well Cvnlrac"vr Don
BYefgdng fMa£tutu, f AerebY cerrfh "Lm the meil(eJ nw (maJ ronrbawfed Fr nccardmree
mub ]SANCACOIC.dt00 orfSANCAC OIC.m00 ryel[CmammHon SfmrdmrL andrfimv
rFY lahu nmiNlms beanprovNedlmbe wellmvner.
23. Site diagram or additional yell details:
You may use the bad< daipage to provide ei pa el wen site details or well
consimction details. Youu mayyalso atlaeh addition.al pages ifneccssary.
SUBMSTTAL MSTUCTIONS
24n, par All Wells: Submit this firm within 30 days of completion of well
cons W ctiea to tho full owing:
Division of WaterQcality, Infoamntiou Processing IIniq
1637 Mnil Servlee Center, Aaleigh,NC 27699-1617
24b. For futect'av Wdis: In addition to sending We farm tv the addrzss in 24v
above, also submit a. wX of this form within 30 days of completion of wall
oemlruction tv the fol lowing
Division 1636 MQuality, Underground IviNC2 Con163 Pragrzm,
163fi Mall Service Center, Aaleigh, NC 27699-1636
the.Fm Water above,
also
submit onel coy of this or ivitbia 30 days
the pledo s(es) well
co also submit one cagy Of this form within f t days of
nmr, cons of well eans[mhtion to the carroty health department of the county
where constructed,
FmmGW-1 Nmrls CaNina DeputmeninfEwuvnman[ and Natural Rloserees-➢ivisioaefWamr Quality I�p� �1(cvaviles.2013
Data site Visited' 7,-9'IS BY: bo /`1Mdo
J

v'E.Q-rHERMAL VVELL
L well cnnm.rmrxnrmvmanan: ' 'MAA 1 4
,an Water pulllty
Pl lineal(
5;�5-A ner,.l loll iop,l<
NC well Contractor Cedgiv.d.. Number
Yadkin Well Company, Inc.
CompmYNa.x
2.Well ennsfraeennPer Mtff: jNTOf oo V/
twmrt appu<nbl=v..n<ann„•<ammern,na P.<. camlpt bmea, rvnm�a, ea.)
3. WrU Me (aLech will use):
OAgricultural
014-1 ipal/Puhlin
❑Geotherma)(Heating/Cooling Supply)
CReaideatial Water Supply (single)
Clnd`strial/Commercial
CResidential Wale, Supply (shared)
Clrrigation
5
Nan-Waeersnnplywell:
OMonitnring
CReoovery
oA,dfarRecharge
pGroundwater RemWiation
0Aquifargta.... and Recovery
ogalmiry Ranier
DAqui£er Tast
CStcnmvater Dlabs,a
CBxperimental Technology
03ubsidence Control
LAeothermal(Closed Loop)
ATraeo,
4. Date wen(s) Completed: P-1-74 wanma A,4t4- 2S7
Sa.w/Iallnaeaiion: .Phone number
�'R 1F� arar�an
FacWty/OrvnerNvna RoJityID!(ifapplieable)
2c7 Ro,.k te6y Ra Z%�ELI"
PLysicel Addrzn, Ciry, and Zlp
Pork P
Cvuary Yvicelldemi&ndenNo. fPm)
5b. Latitude and Longitude in deg, Ecs/miaufts/seconds or decimal desce s.
(ifyrvau Sold, eve leNeag Is adfIckat)
JS" 9.)—, 27-/G. N u.v 08 ct W
6. Is (are)iLewell(s): �Pernmvent or CTemporary
9. Is tLis arepair to an existing cell: CYes or WK.
IJIfat",., w, Jill on, AnmW...flOv.,moiou 4fr I/ell oode. Plor¢dle non-of1ho
l ➢vir mldn'J21 r.—tes sou armrtfu bnekgfd fna,
s.Naanber'nf,vevaemrah'ared, of
' ( II ONLY IR Oe m, eramn�mdml mn
xa. eernreeaxan:
81� eof SedWelt Cvn4zctor . Dzte
B, algnmg mra f rob I M1=,aby aerrb mae me wed(,,wa, d,ara) sen,r„mr=d an a<a Eu,a
rvuh15ANCAC 02C.0100or 15ANCAC 02C.0200 7e11CO.1—Hen Snmm tf,anddma
royyvfdda reeordhva beenprovrdedro eM1ewellomnn.
23. Site diagram m addidanaf welldetaile:
You may use the back of this page to provide additional well site details no vell
amvst.dlcm&Wls. You mayalso attadv additional pages ifnecrssary.
Ferlm•lrcpla o)=<I•on v,nvnormmeuppyn'. ry • 'y° SUBBInTALMSTUCTIONS
,abunona,/,m. '
9. Totalwell depth helm. land surface. 2SS' (ft) 14r.For All )Mells: Submit this£mm within 30 days of completion ofwell
Folannlllylnvellslbroll dapihs Jdb ravr (esanyle-3Qi00'mld3(n)1001 aonstmolionto the following:
10. Staticwater:evei bclmvtop of casing: (fb)
IJrvarer (eva[Is vbvw mmt'. Ilse"Y!! "
Il. Borehole diameter:
12 welleou,0:.elk.rnEthad: Rotary
Divisive ofwaterQunli4•, In(ormntiau Processing Unit,
1612Mai1Servi. Ceatmy Rnlelglb NC 22699-1619
24b. For Iuiection Wells: In addition to sending the form W the address is 24a
above, Elsa submit a copy of this Sum within 30 days of emupletion of wall
constructiontatbefollawiog:
(ire. avgmy rntay, eeblgdbedpasb, nu) ➢ivisiov of Wnter Quality, Underground Iujeeeon Confvcl Program,
F13b.DjAmfIEfiv.tvypI!
ATER SUPPLY WELLS ONLY: 1636 Mail Service Ce h, Rnleigp, NC 29699-1636
Method attest: 24c. Far Water Suooiv @ Ioierflon Wells: I¢ additioala sending theformto
ld (gpm) the address(ne) abovq also submit one copy of this farm within 30 days of
HTH Amov¢t. CUpe completion of well constmction to the cormty health department of the county
whomeogrslnutOl.
For. DW-1 Neil, Carolina Depatmeat ofEmbarament andNe,melRuaarcea-Division ofw9arQuality I U$evisedlan.2013
Data 8it(3 visited! J-J„�d s1 50

c)E0,-T ERMAL VVELL.C®
■
1. Well camracmrlvfmmeNnn: MAR 1 4
Well ConbaRm Neel
rD 5 7�-� Wetpr Ounlily ReQIGnF
'd A h[ o li F)iurt
NO Wep Coll-neor Conhi.rAnNe.bor
Yadkin Well Comnanv Inc.
ComparyNvma
z. oval caaao-nman R<Imit.: lN.0 fl ( 00 Y/V.
Lkf nl( yplhnbinwl/amumrtimzPzrurfrs (r.e, CororW s'on, porinuze, eta)
3. Well Dse (ehcslnvell use):
OAgriculbval PMunlcipal/Publin
OGemhem,A)(Hestiog/Covling Supply) OResidentialWat<r Supply(ainglo)
Olodnslrisl)Commemial OResidentiel Water Supply(shsred)
DA,eiR.r, Recharge
OGmnndwaler Remediefl.
OAquifer Sioregeand Recovery
OSalhrity Benier
OAquifer Tsst
08h,..watarDminage
01b,swilledd Tevlmclogy
nSabsideane Control
v6eonurmal(closed Loop)
07fracer
4. Date Well(s) Completed: 'II'& well i#A,4/A-Z3-1
5e.WeULora6nn: Phone number
�titt�te�f :rand,,,
FacWty/gvnerNanre PaeinryIDA (Sapptieahle)
267 Rack J vi.y� I 22
PLysiral AtlLzss, city, ma Lp
Polk P 79-1
C-1, Pual ld-dfi.e6AANo. (nU)
3h. Ladfude and Longltude in degrees/mlRutealseeonds or acdmul degrees:
(U-11 field, ..ei meanie su(Gcicnt)
3,V' 22., 2.Z/S N &.%' o8.
6. Is (m e)Ne well(s): lRNerlu.—f aI OTempm'ary
Me this arepah to An existingwell: Oyes or WKO
Ib"h"f, A"Arrpll ealnenm well cmntmntm, i,,Aro,.Ihan and up(alq lhnmlme oOh.
repnlr m,da R2l remmkrse.11m, or on the bock//ef haf(ro`rn
S. Number of wells ednst, select:raenmb(nvirb D 6
Forrnn(r jle hftruer oPPYr^el6 GNLYmIrh ge&, eonzhnaimr,Yaumn
mr6.11 oneln,
9. Td.lwell depth belmv land sulfa,,. �-bd- J %¢ (ft.).
For ond'Ve'I'll,A11.1Wplhs rfdbrem (eennQle-3QIp0'mN](ny1p0')
1O.Stan1a1afe1levelbeloav top of casing: (R]
Tfmorer level G be,, .,A,g..a' W.
11. Nol-oUle diameter: C pu.)
12. Well,oustruelion radlmd: {(ot.aTV
Foilnlemnl DaeO Y: '
14.WA4P.RZ ILg
MON TO
DPSCNetrott
I
�lh to
15.0 OR CA M for
PROM TO
mold-Oned wells
DLNI6fLR
ORLINZR Ifa lln Ie
TWCIINPd6 IrL4lIIRIAL
16.1NNRRCASPiGOR.T
p eolGermal dose6-lao
m r$f6R sol s s s ra Tar.,
mom xo
R. R.
f4 R,
in.
P.SCREEN
FROM
t
➢LlhldidR
6LOSa1Zb
TWCI 669
WATCIUAL
ft.
R
V.
18. GROUT
PnOhl
TO
NAMML
aos' A NUVST.IKIRCD&AR[ W, P
ft
{L
19. SAND1OVWZLFACK(ifa
.PROM
TO
1ie�Gle
MATATA,
OETIACnalsorlura.
ie
R.
R
11.
as. DnILL1NGLOG
Fnonr
athch
To
eddid... lebeeh Vuzzeu.
nSessure IOxamee. n nNn.n........ .aln to ems
11
fL
R.
R.
(L
21. AENARRS
of loos Der Bore - I]ia. of loos
22.0
�gfie,we o£ ' r45ed Well Con4ae[or , pZ� //—�&
NAlr15nlgr CO2 ,,dherz6ye.Aryy Amtme.0200 AAmrnnralednr <aca,'herr.
.P 1dANGC92C,b-1, eIdNCACp]G91tl0 Well Connnranor, Srm,dmds mrd thenn
®Y olRtla re<mdhas ba.nprovfded fo lM1a,vell mnrm.
23.6ile diagram or addidonahvell rleGils: II d�
You may use the bacl, of dais page to pmvidp,Rdme,�lw�y A�t r veil
eonstmction details. You may Alsoadml, odditionpa�iperoges'jWWfi�nWecesq 4p SUBMITTALINSTGCTioNS MAR 6G fl g01M
24a. N All Wells: Submit this farm )v (I, 30 days of comylctioll of well
coulloutionto the following: PICKo 9d1'IOIi C'lOCfiiu ,g Uor,
Division orwz ten' li Into' motion DWO)Bngniq
Qun ,
161T Mail Service CeAir', R0,19 r, NC 29699-1619
24b. ror hj,AU,n Well :. In additiantc Rending the fors to the sddfess in 24a
above, also submit a copy of this form within 30 days Of eompletion of well
mlay,.amq aucgpud5 ek) constmcliontO tfiefollawing:
Divislav afwnter Quality, Undergrauvd Ivjeclidn Control Program,
FOR WATER SUPPLYWELLS ONLY: - 1G36 Mxil Service Ceoler, RAleigk NC 29699-1G3G
13e.yield(gpm) Methedditest: ""'Far Wat S I &I"tl WD naddith"ciAendingthafounto
the addfeae(oa) ebovq also submit one copy of this form within 30 days of
13h. DIslnRcliaa type: NTH Amouah CUPS complati" of well O-Aamtian to the e.only health department of the county
wherdconshucted.
F—OW-1 No,US CvnlwaDepatment o[EnvirvnmentaM Nalwal Aesowws-DiviaionafWater Qealiry s��
Data Site V{sited: i-r-IS Bye b� r�+'IJo [yp u1ye.;aealan. zon
L n..• .ee..h . -./In

ojus '
- v IlJ Vv�tluy
2 r'7 JZ,,} Spa,= in ys J� S
/Li,GI S�yse� Alf,
z 87 TC,
C-e-4-'t�J
IJCJVQ�
�wtiWrwaJ
Y -'' � y� ",�= ly'� 'moo✓ _
S Oo
qj
2-2
i"YEoie wc�
Lo
0-7 G
22G
led, v�earee}
22S
of Wan:'llow,rooa
W
C3 83
AJAR 1 4 9016 `
% Ae
2.2.1
Pi
08'7
Watpr Ouelily Pr,gb al Ope,nllnnls
Ash I osLL 11