GW1-2021-07085_Well Construction - GW1_20210915

_.. ....._-...._.._...--_. ___. FRON TO DISC---= EC—il
Well Contractor Name
ft ft
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER(if applicable)
YADIdN WELL COMPANY,INC. rRona To n1An�TER TmCiwr ss iL+RiAi
Company Name �SL D� /
�?J 16.INNER CASING OR TUBING thermal dosed-loop)
2.Well Construction Permit#: Iry C,Et F (°Z(2 r..3 �'� FROM TO DIAM,TER IMCEMss naAMUAL
List all applicable well construction permits(e UIC,County,Slate Variance etc) 4 1 fL 2'6 ft. (/ run• - PvG
3.Well Use(chcetc well E.-se): ft ft in. Ir /^
water Supply Well: re-:oct To DL•.P.Yr'.7"e2 I SLOT SIZE I ra1C1Q+Ess I rs rL_L
❑Agricultural ❑MunicipaUPublic ft, ft in. <_—
❑Geothermal(Heating/Cooling Supply) 99(,idefal Water Supply(single) ft ft C�
❑lndusKrial/Conmmercial ❑Residential Water Supply(shared) M.GROUT
❑Irrigation ❑wells>100,000 GPD rro d TO PIA7"BlUAL LMPLACEhl.NT 1:41iiBOOD C AJ:•IOUNT
Non-Water Supply Well: it, ft. � G,AAJ * �� .�
❑Monitoring DRecovery G/ fG 3 ft
Injection Well: 4210� Is
❑Aquifer Recharge ❑Groundwater Remcdistion R ft
❑ 1fer Storage and Recovery ❑Sal 19.SAPID/GP.AVEL PACK(if opelirable
Aqu rage ery iaityBariier SON TO MATERIAL EMI.P_Cr,Tr 14TA-MMOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Ileating/Cooling Return) ❑Other(explain under#21 Remarks) PR OH I TO DESCRIPTION color,bardness,sail/rack Lym rntin rise,etz
C) ft gU ft
4.Date Well(s)Completed: - / Well ED# L f?`g���a cI ro R. Z 41Z, fL Cyr �►i`�L
5a.Well Location: Phorle # ft- \
-yt-- ff ft ft
,TarktAG 4- J4 nCe x
Facility/Owner Name Facility M#(if applicable) ft. ft.
�U 1 a1- V� 0 z'rl V 1 Qr ft ft` fj l z'
Physical Address,City, c Zip ft fL
U 2j,RRMACn&K`r\
County Parcel Identification No.MN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification: try u i i•Jv~t
6.Is(are)the well(s): Ndermanent or ❑Temporary Sigoatiue of Certified Well Contractor Date
Bysigntirg this form,l hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0No 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill aut known well construction information and aVlain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back of thisforan.
23.Site diagram or additional well details: �
8.For GeoprobelDPT or Closed-Loop Geothermal Wells baving the same You may use the back of this page to provide additional well construction info
construction,only 1 GPI 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary /l
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: T / (ft.) `all%
For multiple wells list all depths ifd,;ferent(example-3@200'and2(a)1000 Submit this GW-1 within 30 days of well completion per the following: /
10.Static water level below top of casing: 500 ( ) a For All Wells: Original fonts to Division of water Resources (OINK), V'
Ifwater level is above casing,use"+`" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Bit Off:Irl 24b.For Injection Wells:Copy to DWR,!Underground Injection Control(1UC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC�27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie,auge,rotary,cable,direct push,etc.) county environmental health dep"ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin over 106,000 GPD:Copy to DWR,CCPCUA e
13a.Yield(gpm) C O Method oftest: ly nix Permit Program,1611 MSC,Raleigh;NC 27699-1611 t .
13b.Disinfection type: 70%HTH Amount: A� OZ DATE SITE VISITED: 7 !'�111-1
/",3 r A,C4t i VISITED BY: bC�3
Form GW-I _ North Carolina Department of Environmental Quality-Division of Wate Resourrces V OL(.. a Reviled 6.6-2018