GW1-2021-07076_Well Construction - GW1_20210915

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Well Contractor Name Zzord TO - DZ.1ri'.=Tim i 1
St? 2 ;ti 2
303 6A �zJY�w'
RC Well Contractor Certification Number 1 Q.�10� 7 1364 (�
�y i1•� a�; 15.OUTER CASING for muld-cased wells=OR LINER if a plienble
YADI{IN WELL COMPANY,INC. FROM TO x4xcrm THICILNLrssXATFJtL4LL F�,s
CompaayName ft. rhIIlin. _7C 1!. �� pu1�
16.DINER CASING OR TUBIINNG 'thermal dosed loo
2.Well Construction Permit#: j�/C� rears To Dlrn�Tltlt zarc�avrss TMUERUL
List all applicable well conshudion permits(i C,C-074+State,Yarlancq etc) +P R• 5- IL 6 114
.f ! l in, sop, t
3.Well Use(check Well L:se): ft. ft � in. V
i s r SLpp1y Well: 17,SCFLiPI
wfiV (t.t,1� rpoti TO DI-tiaT4:3 cLOTsT.G TMCM4ESS Ri:,Tlr'.i.i.
PlAgricultural OMunicipaliPubiic ft
OGeothermal(Heating/Cooling Supply) IOVMential Water Supply(single) I
Olndustrial/Conmercial QResidential Water Supply(shared) 11 Gr.UUY k
❑Irrigation Dwells>100,000 GPD MON TO cIATsEW-v EWLACED NT 1'.i^eTSGD c AJAGUNT
Non-Water Supply well: ft &M,i,,(
[IMonitoring ORecovery 3 ft .24It
P C/
v
Injection Well: fr. ft
OAquifer Recharge ❑Groundwater Romediation
19.SAIIIINGP'AIT P_CK(da Gticable
OAquifer Storage and Recovery oSaiinityBarri& FROM TO M 1ZrluAL EMPLAM.MNTXMITIOD
DAquifer Test oStormwater Drainage I
OExpehimental Technology OSubsidence Control R
DGcothermal(Closed Loop) DTracer 20.DRnJANG LOG attach additional sheets if necessary)
FROM TO DFSCRVTION color,hardness,saithmtk type,grain she,etc
❑Geothermal%eating/CoolingQRealym ❑Other(explain under421/R^em,,arlm) fL 2 Z R s s
4.Date Well(s)Completed: J#�2 Weti ID# "CA tO1 ft Z�( ft- �
5a.Well Location: Phone 036;n J_7.-/329 •'� 2 L ,S 7 ft
(-?�- izCa►blC t r/ ,5 ft± ZZ ft HIJ
acilftytownerName Facility M#(ffapplicable) ft. ft
�106 a 4 4�►�,1,t Znw-16 � ft
Physical Addrrs city: ft. ft
and zip
County Parcel Identification No.MN)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwallfield,a=latllongis sufficient) {� p-- 22.Certification: /� g
b N
6.Is(are)the well(s): Adermanent or OTemporary Signature of Certified Well Conhaatai Date
By signing thisform,I hereby cert fy that the well(s)war(itwV constructed in accordance with
7.Is this a repair to an existing well: DYes or 8No I SA NCAC 02C.0100 or 1SA NCAC 01C.0100 Well Construction Standards and that a copy
If this is a,repair,ff11 out known we0 canstruction information and uplain the nature of the of this record has bemprovided io the well owner.
repair under#21 remarks section cr on the ba6t afthisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-hoop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW is needed. Indicate TOTAL NUMBER ofvvells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. J
drilled: 24.SUBMITTAL INSTRUCTIONS ,
t
r
9.Total well depth blow land surface: 2 (ft) Submit this GW-1 within 30 days of well completion per the following: N
For multiple wells list all depths if d�enurt(example-3Qa 100'and 2 1000
24a. For All Wells: Original £onm to Division of Water Resources (DWR), .�
10.Static water level below top of casing: "�� (ft) Information Processing Unit 1617 MSG,Raleigh,NC 27699-1617
Ifwater level it above casing,use"+"
11.Borehole diameter: (in.) Bit O{f. .3. 39 tf 24b:For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
a
12.Well construction method: AIR ROTARY 24c,For Water Supply and Open--Loop Geothermal Return Wells:COPY to the
(it.auge,,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing o vex R,100,000 GPD:Copy to DW CCPCUA "t
1 s Permit Program,1611 MSC,Raleigh,�NC 27 99-1611 ;
Yield
13a. eld(gpm) F�/0 Method of test: t GPI i 70%NTH i I C�
-f py �J Z' 2
13b.Disinfection type: Amount: � DATE SITE VISITED: I �J�3
VISITED BY: '�L!3 S ,
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Farm OW-1
North Carolina Department of Environmental Quality-Division of Water Resources f %J "SLAW R,••l a�_�nr�