GW1-2022-09506_Well Construction - GW1_20221014

-5TU, CONSTRUCTION RECORD(G`9-1) For Interned Use Only:
I.Well Contractor Informntion:
J—L Vt 1•� 14.WATERSONES
PROM TO DESCRDMON
Will Contact"Nam
ar7� A S7 /(�c� " X So�SEwd ►re aop►t
NC Well Contractor CatiScatumNumbu 15.OUTER CASING for mdti aril rrclls OR11NF.R Bible
YADKIN WELL COMPANY,INC. FROM To DiAAII'rER 7100E ESS MATERIAL
ft. it. iv
Company Name 16.INNER CASING OR TUBING thermal rlosed-loop)
�.-^ . 1, FROM TO D1A MM 7ffi(SOid85 I&AMOUNT
2.WelI CoDstruction Permit#: 2��C,._- I�l)l f"�� 4[ j�S)ErList allapplicable well canatrucfion permits Ile.VIC.County,Stole.Yonance,ve) R -9 it �. 1e• �x3.Well Use(check well use): ft RIn.
Water Supply Well: 17.SCREEN PROM TO DGRCLYE Bl.d[S6L TIBCIOVEES MOAgriculture] OMunicipeVPublic fI. ft.OGeothermel(Heating/Cooling Supply) QZidenti ]Water Supply(single) ft. ft. In.
CIndushial/Commercial OResidential Watt'Supply(shared) 1S.GROUTDIrri 'on OWells>100,000GPD mom To MATEmAL EMPrA�mIT METHODNon-Water Supply Well: ft. ROMorutoring ORecovery 3 ftInjection Well:
ft ROAqujfer Recharge OGrmmdwater Remediation1g,SANIDIGHAVELPACK da linbteOAquifer Storage and Recovery ❑Salmily Barrier FROM TO MATERIAL En1PfAcnazIsTato
DAquifer Test OStormwater Dremage ft• R
DExperimental Technology OSubsidence Control R ft.
DGeothermal(Closed Loop) OTIRW 20.DAD.LING LOG launch additional sheet,Baeansa
DGcothermal(Hesting/Cooling Rehnn) OOther(explain undm#21 Remarks) FROM To DEarIUMItoN rileslusitnta,wanorrr ell.
49 IL Sal
p
4.Date Well(s)Completed: /- q-'"ZWeRIDp�]�7�r' as(? G If L R' tt" Ond q, Z J
a 5s.Well Location: Phone # f-Ck- 7_O 1 R �J R ed Xer 1/C ai/C cS
'�* jam^ S�e�ccr-45s•C��- qc �s ft. R
r� e
Fmlity erN a Fad*1D#(if applicable) R it.
'V l■� UL'�COaJ`)vyC ft. ft OCT/�� \)it.f TLl t'a"TteY-4`� �!/�M rim � � G 20
R R
Physical Address.City.and Zip - 'IF
21.RmvrenuR ...
unit Ta-..�
county Parcel LlenfiSeation No.(PIN) !I,I,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: CPI
(jfwell field,one let/long is suf icieot) 22.Certification:
3CelCt CC'
IJ N •74 . 7Cl4LS - W J Q_1Y �z
6.Is(are)the well(s): Asmanent or OTemporsry Si of Ctpm Well Contract. Dee
By signing thisform,Thereby cer0rhat the wells)war(were)contracted in accardance with
7.tree this a repair to an existing well: DYes or n 15A NCAC 02C.0100 or 15A NCdC 02C.0200 Well Consbuetwt Stmrdards and that a ropy
Ifthis is a repair,fill oat known well construction information anderploin the nature offhe ofthis record has been provided to the writ owner.
repair under#21 remorkr section or on the backufthisform. S
23.Site diagram or additional well details: `
S.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 js needed Indicate TOTAL NUMBER of wells (edd'See Over'is Remarks Box).You may also etferh additional pages if necessary. Jz
drr7led: l 24.SUBMITTAL INSTRUCl'IONS q'
9.Total well depth below land surface: J Q.�' —(H) Submit this GW- within
For multiple wells list all depths/fd$ere nt(emmple-3(a)200'and 2@100� 1ithi 30 days of Well completion per the following:
Sp ' 24a. For All Wells: Original form to Division of Water Resources (DWR),
liwater levd 10.Static
level b tap of teeing: (ft.) Inform es ation Procsing Unit,1617 MSC,Raleigh,NC 27699-1617
el Is G above casing,
,use"+"
Bit Off:�( 24b.For Injection Wells: Copy to DWR,Underground Injectiou Control(NC)
Il.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC27699-1636
12.Well Construction method: AIR ROTARY
.24
(ie,auger.mt,ry,Cable,direct pusb.ere) couaty environmental health department of Geothermale County Return Wells:
installed
Copy to the
FOR WATER SUPPLY WELIS ONLY: 24d.For Water Wills rodncln over 100 000 GPD-Copy to DWR,CCPCUA
Permit Program,1611 MSC,Ralmg N 27 -1611
13a.Yield(gpm) d Method of test: ) '1
13b.Disinfection type: 70%HTH Amount I�a 14 OZ DATE SITE VISITED:
,,__re, --- --- - -- - VISITED BY: "