GW1-2021-00238_Well Construction - GW1_20210125

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W7C+ ILL CONSTRUCTION UCTION RIZCQ:g �4�•W_�.� For Internal Use Only:
1.Well Contractor Information:
" �+�, tl®yj� ':Y9:��iAp'?=R�.01�`r,5:•�:.,.. .• ,:.....
WdlConttactor ame FROM TO DESCRIFi10V
NC Well Contractor Certification Number 15,0DI)l,°g;U-S]UN-(fpr•nniti=cased Weis 0&LIt�iEB if u 'ia
Yadkin Well Company Into PROM To DTAtYt^r1 R �Mucxn�ss� X TE xA.
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Company Name i"C (/r fh. i��l' ,; vc"
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�,1y +.16iI1!IPTH'12 Sim-,r"COFtTT1B�1 C" go'tlijLiil oiedIoa` .
2.Well Construction Permit#- —FL`,)� PROn? To DIAL MT-?t TEIMOMS �:•~X&TIU TAL• -
List all applicable well construction permits(i.e.(I1G County,State,Variance,etc) $ ft.
3.Well Ilse(check well use): ft, _.
Water Supply Well:
PROM TO DSLIEs�LT.t;R SLOTSM ,TEICHNESS I n7ATEsRIr4s.
Agricultural nMunicipal/Public 0 f. im
Geothermal(FTeating/Cooling Supply) esiderrtial Water Supply(single)
f; � w.
Industrial/Commercial DResidential Water Supply(shared)
_ •Inj `on FROM TO 'MATE,Ra 1,...: MaLAICERMMAW1210D&All OU T
Non-Water Supply Well gw,
(Monitoring [MIRecovery ' ft �`� ft
Injection Well: Y
ft ft:
AquiferRechargc C�GroundwaterRemediation 1°.S !ER9 1;YA•CR(if a'i�licnble)
Aquifer Storage and Recovery DSalinity Barrier FRord TO MATEF.TAS, I EMPLACMUMIM MEMOD
Aquifer Test ISto nt've' Drainage
f {
:Experimental Technology C)Subsidence Control zt v
['Geothenmai(ClosedLoop) MITraeer 20:� tRT�I OG'ztfar3ia3critrousae'stsiinececs"
C Geothermal(Heating/Cooling Return) C Other(explain under#21 Remarks) FROM To I 1)=CRIPTION(core,bardnm,soitimck e,rain s"eic
oft
Syf
4.Date W01(s)Completed:.b� ° ^Well ID# ` l ' ,g�ei �qm a
Sa.Well Location` Phone 17.11mber �fc 4Qd f- fpieef 6
ft
AA
Facility/QwnerName Facility ID#(ifspplicable)
Physical Address,City,and Zip
���t� .2Z:It1ti1L1917�5.' .
county UVO Parcel Identification No,(PIN)
51).Latitude and longitude in degreestminuteslseconds or decimal degrees:
(ifwell fiellffjdd,,7 one Mang snf dent) ��j3 22 Certification:
6.Is(axe)the well(s) Permanent or 3_ii Temporary si mre of ce • d We'll Contractor , Date
By signing this form,1 hereby cerg5;that the ive11(s)was(were)constructed in accordance
7.Is this a repair to an exisdug well: EliYes or J&o with 15A N.C4C 02C.0100 or 15A MCAC 02C.0200 Well Construction Standards and that a
ythis is a repair,fill out larmtm well construction infarmatiatxand explain the nature ofb e copy of this record has been provided to the Iveil oxmm
repair under AM remarks seofion or ni the back ofthisfarm, e Ny
23.Site diagram or additional well devils:
S.For Geo ha rm ^d same You may use the back of this page to provide additional well site details or-well_
probelDPT ox Closed-Loop Geothermal Wells
construction,only I GW 1 is needed_ Indicate TOTAL iSfwells '�� construction details. You may also attach additional pages ifnecessary.
drilled: r• � � (. i�'a TAL R3STa�17CTIOTdS
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9.Total welldepth below land surface. �! � ') y7da. Far All Wells: Submit this,foror -Mthin 30 days of completion of well
For multiple wells list all depths ifdifferrnd(example-3 r( 00'aad2 0? ^< Oi J
<` �^�- construction to the following:
10.static water level below top of casing. `` Vh) (Division of Water Itesou,-ces,Wo•nation Processing Unit,
(flouter level is above casing,use"+" \`y1�' T'T 1617 Mail Service Center,%- leigh,NC 276991617
i
41.Borehole diameter: f (in.) PH- cff n 1
24b.For Zuiection Wclis: addition to sending the fora to the address in 24a
above,also submit one copy of this form�fhin 30 days of completion of well
12.Well construction method: construction to the following:
@_e,auger,rotary,cable,direct pus%etc.) I
Division of Water Resources,Undergromid Injection Control Program,
P011 WATER SUPPLY WELLS ONL17: 1636 l�ar'1 Servica Center,Raleigh,NC 276991636
13a.Yield(gpm) Method of test: °y /Wv 24c..For Water Suuuly�c 7npectioa PVeIIs: In addition to sending the form to
the address(es) above also submit I 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 constructed_
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Fain GW I NorthCamlim Department ofEnviromnental Quality-Division ofV'raterResources Revised 2-22 2016

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OWNERS NAME: BUILDERS NAME:
DDRESS. ADDRESS:
1'EI�IE OFFICE#
CELL#
COMPLETE IF INVOICE IS BILLED TO
Contractor