GW1-2022-00236_Well Construction - GW1_20221216

WELL For Internal Use Only:
1.Well Contractor Infor runtion:
t,-f-(,'t;1 Y )-'�1 14.WAT'ERT,ONE6 -
WellContrazttuNema loom I TO [IDESC—rOTION
3a�
NCWe9C0ntreomr Co65®tirmNnmhc
ls.OUTSRCASIN tormnl4-use3 wells OALINER der huhle -
YADKIN WELL COMPANY,INC. PROM - To_. -nussarart - 'rRII UMS MATERIAL -
CumprmYName CN.4.14A 9 fr_ Ig`S7ck ]6.IIiNER
it
//''p CASING OR1TIBING wlhermal closed-loo ,
2.We0 Construction Permit#: 7Y'O FROM To DIAa'rM TTncrtlmss MATmvm
LLB allapplicable wall eomtructlonpemtu(1e flfG Co—ty,State,Yad=cr,etc) ( R it 1 Ira in. (.p jk)1 '-♦, •I
3.Well Use(checkwell use): fE ft. in.
Water Su _ly well; - 17.SCREEN - - -_.
PP - FROM To. . mes>Brmr :SLarsrze THICIMUs.._ mATF "
DAgricultaral LD danicipaUPublic R, k. - to.
riGmthennel(Heating/Cooling Supply) tyicesidential Water Supply(single) ft. it. - in.
DindustrisUCarmneacial /pResidentisl Water Supply
(shared) 1&GROUT
mrigation DWalls>100,000 GPD PROM M _ MATMUCAL m ACEMENTMareon&.AMOUNT
Nou-Water Supply Well: O ft. R.: �?th the- Q' V i y
OMomturing 'C9Recovery IC ft -
Injection Well: ft. 1L -
DAquiferRenherge OGmrmdwaffi Remediati® 19.SAND/GRAVRLPACK der 'cable - - _
OAquifer Storage and Recovery DSalinity Beerier PROM TO ImATERtnL iii6actavo warl'atut.
DAquifar Test OStormwater Drainage it, R - -
DExpwimeatel Technology OSubsidence Control ft. -It. -
i7GeMhermal(Closed Loup) IlDucer ` 20.DRHJMGLOG attarbadditioaalshmtsifn - - - -
Geothermal. ating/Cooling Rztom) OOther(explain under#21 Remake _PRom ToD nastzsmtTON error.sa wala,ek ,s,am-
a.Datrwen(s)Completes:. �')G'� ?. We1lIIl#¢+ � Ica t;. I _ - R • ,�OG..
Sa.Well Location: Phone# 76 _ I d._' it. r7 fc ,Y (i`ag C.i 4.
�E rZ "',44 hug 7/ ft. , , R r „ 4:
Fmlity/Oam¢Neme FacitilyIIM(dgrpliuble) I v( tL 1 to q fiYl; ':-
75OU A4�1« /e C yer,, ft. R
MysicalAd&--%City.-if* R ft.
2LREMARES._
[Duty Pa¢el Identi5nti®No.(PIN] N I
Sb.Latitude and longitude In degrewhstintitedsecouds or decimal degreea: ID
(ifwag field,no let/lmgja m ifixient) 27.Certification• .�C'�' I) i: n ..� •-.•., _
N %`j�`
ermaoeut or ➢Temporary %iduamreafCertifiedW,,UC,atnn".
6.7s(are)thewell(s): Date
BystgnhWthtrfarm,IherebycertifyMat ihewell(s)was(were)emuhuetedln aacordmrcewith
7.Is this a repair to an ndstiagwell: OYes or fN0 15ANCAC 02C.0100 or ISANCAC 02C.0200.Well Conshmaimt Standards oadMat a:ropy
$ihlTuarelmfr fllfoW brawn wdlrwrslruCloa fnformntlan derpfain thenature offhe efthlswcardEas bempmI&dlo the well owner.
rgwrsmdsrf2l remmksscffan or an the back ofihisfomr.
23.Site diagram or additional well details:
B.For Geoprobe/DPr or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
canshvctum.only I GW-1 isneeded lndicatcTOMALNUMBERofwells ( See dveeinRcmEI3 Boo).You may also attach adddionalpagesifneoessmy.
wed' l - 23.SUBNUT AL.INSTRUCTIONS
9.Total well depth below land surface. 1.6)Lt L041, (fL) Submit this GW-1 within'30 days ofwell completion per the following:
Forandaple veils Hsi all depihs 014Fef(example-3Q200'a;Td2®f00�
10.Static water level below top ofrubw. (fL) 21a. For ALL Wells: Original farm to Division of Water Resources (DWR),
If"Ier lend is abom=ft Use"+" Qa[ lafosmation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
IL Borehole diameter:._ ►o ,(In.) Blt Dff' 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(TUG)
Progrmn,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY_ 24c.Far Water Suonly and Open-Loon Geothermal Return Wells:Copy to the
(ia angv,mtmy,oaulq directpmb,err) - county eovirmm�mtal health department ofthe county where instal]ed
FOR WATER SUPPLY WRT..I ONLY 24d.For Water Welie rodurin over 100 I OTD., Copy to DWR,CCPCUA
Peanut Program,1611 MSC,Role ,NC 27699-1611
t 13a.Yield,(gpm) Method oftest: 9/ rf
a Z—
i 136.Disinfection type" 70/a HTH Amount: DATE SITE'VISITED:
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J_ VISITED BY: