GW1-2021-06793_Well Construction - GW1_20210809

"GEO-THERMAL VVELL .CONSTRUCTION RECORD
WVJeiJV1i CONSTRUCTION.kYt'I.OAU! ror Internal Use ONLY:
This form can be used for single or multiple wells _ I
1,Well Contractor Information: 00,
'� 14.WATER ZONLS l
l�9 197tJ 1('3 t 1� �,4 � FROA1 .TO i DT-gr PT10N
Well ContractorNaoie � � feat 1 D ft. D I�y P�. o
/ ���v �`fjyr; ft ft.
NC Well Contractor Certifieatiou Number tJ� C3 15.43UTER CASING for mulh•cased tireUs OR LDVBR if a lies ie
PROM TO DLAMRTEA TffICIINF.SS 1<LA71?RIAL
Yadkin Well Company, Inc.rdt1' fL, ft. In.
Company Name �� 16.INNSR CASING OR•TUB G ebtyermal closed-too
j_ 6 Y FROM TO DIAMIrIIA THICIINIISS MATERAL
2.Well Construction Permit S: �-��® (� � D / !t•
List all applicable well caismvction per•ndrs(i.e.Coim%State,i✓orlance,ere.) '—
ft. ft. in.
3.Well Use(cheep well use): 17,SCREEN
Water Supply Well: FROM TO DIAhIMR SLOTSM TFUCIRIESS hIATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL it:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irr1 ation FROM TO MATERLAL EMPLACEMENTh12THOD&AMOUNT
3�ft- fL
Nou-Water Supply Well:
❑Monitoring ft. ft.
❑Recovery
Injection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVR;LPACK if■ Iicable
FR0112 TO❑Aquifer Storage and Recovery ❑Salinity Barrier EMPLACEMENTMETHODier fL R
❑Aquifer Test ❑Stormwater Drainage
R ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLINGLOG attach additional sbeels ffnecessitry)eothermal(Closed Loop) ❑Tracer FROM' TO DLSCUPTION ceter hardness,sAlredc type ersin Size.ere.
❑Geothermal(Heating/Coblin Return ❑Other(explain under 421Remarks ft, �n ���
4.DateWell(s)Completed:
, We11ID1iAA --7 (Jn 8V 6/te
& ft.
5a.Well Location: Phone number
' ^ 1 ft• ft
fL
Facility/Ownu•Nante Facility MR(ifapplicable) ft. {t
G�$ Wln�i�lcod L� l�t cwt� 28'C-01 n ft
Physical Address,City,and Zip
• 21.REMARKS
11?a 4 c; . 8'0
County Parcel Identification No.(PIN) Of loolps iper Bore
( *6-- h Dia. of too sj_
5b.Latitude and Longitude in degrees/minutes/seconds at-decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W
of"edWell nl<actor Date ik
6.Is(arc)the well(s): ❑Permanent or ❑Temporary y signing lhfs form,I hereby cert6 deaf rite well(s)bras(were)constricted in accordance
"'ft"]SA NCAC 02C-0100 or ISANCAC 02C.0200 Well ConstnicBon Srmrdards and that a:
7.Is this a repair to an existing well: ❑Yes of ❑No copy ofthfs record has been prm/derl to the well civne:
If this is a repair,fill ad biowr well constriction Irlforniarion mid explaiq the nature ofthe
repair tinder 911 remarks section or on the back of fhfs form. 23.Site diagram or additional hell details:
You may use the back of this pag e to provide additional well site details or well.
S.Number of wells constructed: O �" construction details. You may also attach additional pages if necessary.
For rnnitiple h fection ar non-lratersupply wells ONLYwfth the sate constritcliavi,yati can
subinfr one form ^�Q/�r SUBMITTAL INSTUCTIONS
9.Total well depth'below land surface: J a y (ft) 24a. Por All Wells: Submit this form within 30 days of completion of well
Fa•undtiple wells list all depllu lfde•enf(example-3C3a 200'mad]�100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
Ifwater level is above casino use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borebole diameter: (in-) 24b.Ear Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.'Well construction method: $ptary construction to the following:
(i.e.auget•,rotary,cable,direct push,etc.)
Division of Wnter Quality,Underground Injection Control Program,
FOR WATER SUPPLYtiVELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.I'or Water SuoDTv&roiection 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 constriction to the county health department of the county
where constnucted.
Font OW-1 North Carolina Depaitsnent ofEaviromnent and Natural Resources—Division of Water Quality Revised Jan.2013
Data Site Vi si f-ed = Bv: