GW1-2021-06826_Well Construction - GW1_20210415

To
Well Contractor Name }'
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NC Well Contractor Certification Number r 15.OUTER CASING(for multi-cased;;ells)OR LIBiEsd(if aglicable) 1s' e
Ai'r� 2021 FP.3N? TO DIr, SS P:IATE 31L
1'ADI<iiJ WELL COMPANY,INC. IETE? Tt iCIiNE_
'i ft.- •� ry ft. tn. 11 3
Company Name, IIfalli.aesllCC£�S.i ii. 3 �® Z5 CCG S e�
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tp9� t'011 16.INNER CASING OR (geathermal closed400p)
2.Well Co-SeII a+ctlon Permit q — Ef rROmI TO I DIAMETER TMCKIMESS ERIAL
List all applicable bell constniction perudts(i.e.UIC,County,State,l'ariance,etc) ft. I 7 ft. IV C_! " `
We1 lJc�(o=e-,efi?:-'1 =,): .. •7 �7 .2. V ® �r,b J/T e.
❑Aa"'iflll In�i ❑1+'it?iiiril;al/FUlii;r: V I I _ Iy�
❑(''eothe_nal(Heatisig/Cooling supvly) .estUcntill Wm't?r Supply(single)
❑industrial/Conin:ercial ❑Residential V+cater Supply(shared)
13.G,r_DaiT
❑ling£rou ❑14iclls> 100.000 GPD F +e. +' ' ' dOU w
®well: // y<Hon-dYc,u_� Suppl
❑N/foniioring ❑Recc✓ey
n
V
f,. ev
❑Aquifer Recharge ❑Groundvvater Remediation
1'9.S:Lr°D/G-411;gsL PACK-(R aEiie:,37r)
❑Aquifer Storage and Recover), ❑ FROMSalinity Barrier FROM rl TEPI tI�L EPL:�CEi:IEA'T ZvIET3^n
❑Aquifer Testj ❑Stormwater Drainage rt.
❑Experimental Technology ❑Subsidence Control ft.
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if oecessarA
FROM TO DESCRIPTION(color,hardness,sailtrock type,gain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
�g
4.]Date Well(s)Completed: 3�� Well ID# AA t0 " clQQ &PIC 33ft 30
CAtry �j've` IX2f 9 j� ft. ® ft.
Sa.Well Location: Phone # ,? _ ��� '0U 2 9 J V
yg ft. �ry ft. S-
(A M 51. t V (A S/ 0 U/Sinn
9G} it. ft.
Facility/Owner Name gg p ` Facility M#(if applicable)
1 ft
! 1 1 14 0iis e. O d Fo r f . ft. C�
Physical Address;City,and Zip ft. ft.
A 1� wZ ®6.� $-0o _36-03cl RE;zlAttiCS
County Parcel Identification No.(PIN)
5b.Latitude a id longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
_�9 3 , 3
6.IS(are)the ell(s):'Xermanent or ❑"Temporary Signature of Certified Well Contractor Date
By signing thisfonn,I hereby certh+that the well(s)was(mere)constructed in accordance with
7.Is this a rep it to an existing well: ❑Yes or XNo 15A NCAC 02C.0100 at-15A NCAC 02C.0200 ld'ell Constnicrion Standards and that a copy
If this is a repair,rill out!Drown well constniction information and explain the nature of the of this record has been provided to the well owner.
repair raider 921 remarks section or on the back of this fonn.
23.Site diagram or additional evell details:
8.For Geopro e/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to provide additional well construction info
construction,oi ily 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'its Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 -?_ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple well list all depths ifdiereni(example-3 rt 00'and 2 c(r)100')
Q (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static waterlevel below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivater level is a ove casing.itse Bit Off: 41031 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole dameter: (in•) Program,1636 MSG,Raleigh,NC 27699-1636
AIR ROTARY i '
12.Well consti uction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental Health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
o , Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp ) Method of test: I'i j
C41 i° I i
o e[tl' t l
136.Disinfection type: 70/o HTH Amount: �p OZ DATE SITE VISITED: li
VISITED BY:
Form GW-1 Nordi Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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