GW1-2021-01826_Well Construction - GW1_20210503

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�Well&ntractor Name I
Q4Q A RECEIVE ft. I -to ft. -3 6,Pen CID
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NC Well Contractor Certification Number — i P
MAY X 3 2021 15.OUTER CASING(for multiL-casddl wells)OR L Rfiif applicable)
YADKJN WELL COMPANY,INC. TO DIAMETER I fin MATERIAL
Company Name InforM3tition voceS51149 U in.
I
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R 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 6-3 g - FROM TO . DIANICTER TEEICHNESS MATERIAL
List all applicable well construction permits rk e.07C,Cozinly,State,Variance,etc.) 41 ft. 514f ft. 1 in. 09
3.Well Use(check wei;use): ft. ft. ' 00 641V
W S 17.SCREE N
,2ei.-Supply TO DIUMETER SLOT Slit I TH-10-011ESS I R.LA L
gricultural FROM
CMunicipaUPublic ft.
OGeotherrnal(Heating/Cooling Supply) D-Residential Water Supply(single)
it ft. in
Mdustrial/Conimercial OResidential Water Supply(shared) I&C-ROUT
DIrrigation OWells>100,000 GPD FROM TO — HATEEINTAL E111PLACEAENTNMT 110:ODMAJ,-IOUNT
Non-Water Supply Well: 0 fl- 11 ft- F1!5 Pourei 11 SS
DRecovery U ft.
Injection Well: 0"Ick:6rM PyftvJ CJf
k, ClAquifer Recharge OGroundwater Rernediation ft ft.
I 19.5AII]DIG1R,A iLPACE(dapplicable)
OAquifer Storage and Recovery 0 Salinity Barrier
I.- FROP.1 TO MATERIALM
EPLAr—P BlEr4T BEE TECOD
OAquifer Test OStormwater Drainage fL
DExperimental Technology OSubsidence Control ft.
DGeotherrnal(Closed Loop) OTracer. 20.DRILLING LOG(attachadditional sheets if necessary)
OGeothermal%eating/Cooling Return ❑00ther(explain undir#21 Remarks) -ffo—al To 2CRIPTION(color,hardness,sail/rock type4 grain--size;. Or.)
O ft Al'? ft
4.Date Well(s)Completed: Viah;- well ED#AAO-V-V-o 1003 It
Sa.Well Location: Phone # 7tq- 219- ft&CO
II ft. ft
Facility/Owner Name Facility ID#(if applicable)
Pa -w
Physical Address,City,and Zip ft. ft.
A4.q. A i l eeG G u y
21.REMARKS
County Parcel Identification No.(PIN) J GPM before Frac t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: *7 On Af4,r-
(if well field,one lattlong is sufficient) 22.Certification:
6.Is(are)the well(s): permanent or OTemporary Signature lbfCe ed Well Contractor Date' T
By signing thisform,1hereby certi(y that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or BNo ISANCACO2C.0100orl5ANCACO2C.,0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this p aige to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: too 3 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of Well completion per the following:
10.Static water level below top of casing: W 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off* 5 Mel 24b.For Injection Wells:Copy to DWR,Underground Injection Control (rUQ
Program 1636 MSC,Raleigh,NC 27609-1636
12.Well construction method: AIR ROTARY
(Le,auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I
24d.For Water Wells producing over 100
..GPD:Copy to DWR,CCPCUA
T
13a.Yield(gpm) Method of test: A,Or Permit Program,1611 MSC,Raleigh,NU 27�9-9- 6-1
13b.Disinfection type: 70%HTH Amount: L+S oz DATE SITE VISITED: 2--22
VISITED BY:— low
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6
Pp,I C E -1
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