GW1-2021-07072_Well Construction - GW1_20210915

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Conhactor Name � e,,,�•
it.TO �r, u
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NC Well Contractor Certification Number C1�Q e\��
C rL,;;-r 15.Oi1T'ERCASING far m ulti-case ells OR LINER �a plicn6le
YADi4N WELL COMPANY,INC. ^c?�C�r pn FROnq TO DW1'n+TrR TMcrwaSS ;RIaL
1 ft. ft in.
Company Name 1 ( 2 S 3 3rz" 'i=J'� 3 16.WER CASING OR TUBING ottrernral dosed-loop)
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2.Well Construction Permit N: 1 Q FROM TO DIPIKLTL+R :Tffi(3QVCSS wry rrrRrer.
List all applicable well construction parmils rLe.UIC,County,Slate, Variance,etc) ' ft It
3.Weil Use(check well uxe):
17.SCr_r Z i l
Water Supply Well: 8r:01.i TO DiANET-e:t SLOT SIZE TurcIUlEss Pl;. sr_y
❑Agricultural ❑Municipal/Public ft. f£ in.
❑Geothermal(Heating/Cooling Supply) is,//midential Water Supply(single) it, ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.CROl1 T
❑Irrigation ❑Wells>100,000 GPD rrortt I TO PL+ -EW-L KJ tQLACEr.>rNT HE-1901)r.+1:rouNT
Non-Water Supply Well: n ('' ft
❑Monitoring ❑Recovery Pn:544irs Pd0'
Injection Weil:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAS/GRAVEL PACK(if applicsbL)
❑Aquifer Storage and Recovery ❑Salinity Barzier rROnr TO MATIERIAL LnOUCE-Mrre TvM,78i•oD
❑Aquifer Test ❑Stormwater Drainage fL %
❑Experimental Technology ? ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal 04cating/Cooling Return) ❑Other(explain under#21 Remades) imons ftI TO DBSCRlPTION color,hardness,sairimck type,grRin,tee,etr-
4.Date Well(s)Completed: - y Weu w#/AA0--112'✓ ,�ft' ft E�rtf�is �r
5a.Well Location: PhOl.2e # 60Y'y�, So -J a Y m&on 6(gg{ 0,1, A O
INS/ cv q n Y� ft. iti /��f�:f re
FacilitylOwnfrName �- Facility ID#(if applicable)
ft.
-� L.aAez " h U,
Physical Address,City,and TIP ft
f_ .p ft
*!O�"s,es • 2L RRMAPM
Comity Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is skied) 22.Certification:
6 ® ® �� d] et N PW 19:r 3®7 W
6.Is(are)the well(en A ermrment or []Temporary 'Xignture of C ed ell Contactor Date
By signing this form,1 hereby certify that the wells)was(k ere)constructed in accordmtce with
7.Is this a repair to an eristing well: ❑Yea or M4 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this it a repair,full out brown well construction information and orplafn the nature oJthe of this record has been provided to the weal oxmer.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction job
construction,only 1 GW is needed. Intricate TOTALNUMBBR of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SURNIMAL INSTRUCTIONS
9.Total well depth below land surface: 4641: (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(ewmple-3@200 and 2(a)1001
7s"' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water Ievel below top of casing: ( ) Information Processing Unit,161.7 MSC,Raleigh,NC 27699-1617 t
If water level is above casing,use"+" C
11.Borehole diameter:. Q (in.) Bit Off:��_ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
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12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(it.auger,rotary,cable,d'uect 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,
-J � Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: e� dJ�� K C'
o DATE SITE VISITED: 7- 2-21
13b.Disinfection type: 7D/o HTH Amount: �J.S OZ
VISITED BY: �L1�
Form GW-1 r'.^_ N th Carolina Department of Environmental Quality-Division of Water Resources .1
Revise 6fi-2' 018' 1
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