WI0100356_Geothermal Well Construction Record (GW1)_20160101

;his focal can be used £orsingle or multiple vaelis
I. Well Coalractor Information:
Well Coutractoc Ndme
—26'71-4
NC Well Contractor CerdScaCion Number
Yadkin Wel 1.. Company, Tnc
CompanylVazne
y�
2.Well Construction'ReroAt9:
List all rrpplivable ni elE ,e. Cournly, Slofe, Var•lams, eta)
3. Wal Use (theck►vell use);
WMer Supply Well:
DAgricultural
DMunicipalRublic
OGeothermal (I3eatinglCooling SilppIy)
OResidential'Water Supply (single)
[MadustriallCommercial
❑Residential Water Supply (shared)"
DIrr1 ation
'
Pion -Water Supply vvell:
[]Monitoring
❑Recovery
Injection Well;
OAquifer ReQharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑ salinity Barrier
RAquifer Test
❑stormwaterxlrainage
❑Ruperimental TechnoIogy
Dsubsidenee Control
43eothermal (Closed Loop)
Mraeei
RGeothelmal(HeatiaglCoblingRetzun)
Lathe- (explain under421RemarIes)
4. Datc Well Completed: - I ' / � We) IID#����
5a. WellLocation: Phone number
Facility/7.7N. Facility ID9 (if applicable)
Phyc1cal Address, -ty en cftp
County Parcel Idendficadoallo. (PIN)
5b. Ladtude and Longitude in on• dccinnal degrees.
(iftveil field, on6 latllong is suffic ent)
,3(.4 ac-o 33ci-- -II,, V" tS q.. 112 W
6.Is(rtrc)the zvell(s): Aerinanent or UTeznporary
7.Is this a repair to an existing )yell: DYES or lb§D
Ifflrfs is a rapair ffll nuI larariar anall constnrcllorr irfonrralfoa and erpledil the }ralra•e of the
repair• it rder 921 t-aineirkr section or on the Lack of lhts farwr.
G. Nurnhr oflvells twistructcd- P
Fo]-]trirlffple 14evifair Or110rr-51•afersriopij, IV,Us OMZYIVA 176 Sadie coHS •11efiont yorr Can
srrbarit one form.
9. Total lvell depth beloiv land surface; _ S-o a (ft
For 711 rfhpq e nyeils Till all depdrs ff dryerunr (erampla- 3Q3M' and 2QI001)
IturIniemal Use oie1.X:
433979
uyr.Y.,�.-A vnuYv eoclleima�
crnseu-loo
31R0i4I
I TO I]iAhSETTSr
TIIECKIVTSS
]4LATLrtiTAL
ft.
fh, in.
ft,
ft.
I7• SCi{EEN - —
L'90M TO I)MVETLR SLOT SIZE TIiICIQVESS MATLrML if
fr ft.
ft. ft. in.
is. cltoux
FRONT
TO
I NIATFRUT.
ENIPLACC14ipNT NMTFIOD & AMouNT
ft.
Ranonite--
Pump
ft.
ft.
19. SANp1Gi2AV�LPdCi{
ifs liraLle
. PRMM TO
H'LA TZRLAL
ENIPLACEiWNT METROD
fL ft.
ft, &
r'ROrTI
TO
BES CnrPTl Nfcaloi- Nt iATws, zoillm ck
ly r7e.arpir, eL -. atc.l
ft.
ft.
�r
ft.Xftv
ff--
ft.
fr.
ft.
fL
f�
ft.
ft.
ft,
ft,
ft.
21. REMAR1zS
1�
of
l-ao s
1oe_r
Bare
i Dias
of loon_
22. Certit'ication:
a6
of Ceowd Wall Connnctor
Data
S
By sfgrri]tg this forn , I hereby Cer hjy Thar tha T 11(ya as 6'ffr q) corslmded in accordance
-with 15A XCAC 02C,0100 or I5ANCAC 03C.0200 Wreli Corsfiveliarn Standards and thel a
copy of fbts retold has been provided to the 11•211 inmer•
23, Site diagram oradditionahvehditails:
You may use the back of this page to pr4vida additional (veil site details or iveli
constniction details. You may also attach additional pages i_fnecessary,
SUBMITTAL INSTUCTIONS
ccrion- A,Il FYcIIs: Submit this form lvith CE60' I � ell
canstmctionto tlza f�llatl'uI ;:
10. Static Ivater Ieve] helo'w lop of casing: (ft.) Division ofWater Quality, Infoz•cnati c gz �
If water level is above rrtsiirg, use"t" .1617.1i'.I-ill Scrvicu Center, Raleigli,F IJ!" 016
11. ]dorchole diameter: (in.) 24b. for 3nieefign Yells: in addition to s� i �r .irr� k s�jbx ga
shove, also submit a copy of this farm wi[I-il� -d tI etnon of wall
12.Well construction method: tam above, also
to stitm follovpy
(i.e. anger•,mlazy, cable, dirzc(pusln, etc.]
Division ofiYnter Qualify, lUn&rground o Inzj c " C"i { o pa � _........."
FOR 1WATERSCTPPLYtiVEi I S ONLY:
Mail Service Ce Raleig�ts;�[ ���'���r �� nicer :a
13a. Yield (gpm) � I4tet1lod attest: �"� 24c. ForWater Su ❑lv & Iti ection Wells: In additionto sending the form to
tha address(es) above, also suhinit ona copy of this form within 30 days of
13b. Disinfection type: HTH Amount: _ " CU j
completion of I:VA constriction to 11e cozurty hfa[d&ep2A&nQ0 j&a county
where cons hicted,
Fomr GW-1 Plordl Carolina Dapattment of Environment and Natural Resources --Division of Watzr Q aiity l Resisacl7an. 2di3i
UM4ter OLKillty llr;niort,:tl flt+tart:Ht]rg4 E
Dace Site Visited:- � "'�3'� S� By o � � � Pt;sl :•,,' . irq:r7r:,! t)`fi;,,:. i
.. • .....
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