GW1-2021-05568_Well Construction - GW1_20211013

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NC'We11 Contractor Certification Number 45.OUTER CASING(for multi cased c;+ells)ORLIMR(if applicable)
YADI<6P11NCLLCOMPAIJY,INC. S�lr� MOM TO nULr! ictt Tnlclaa ss r�Tcela�
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Company Name '' ' BG'y t I hy) 3 G_ ,�s`6 �R CJ M.t11N)P.CASING OR TUBING( eothera i dosed-loo 1
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Kstollcpplicable aellcot»m7(ctiompermits(i.e. (11C,CorNrtY;Stare, MG1-iamc L2.Welt Co s sctioi)?e;r,tit#: 0477 J t
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❑Aquifer Test ❑Stomi�h ater Drainage
❑Experimental Technology ❑Subsidence Control ft. ir. I�
❑Geotlermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sLe�ts if necessary
FROM _TO ➢RSCt"i.t"PSYON(color,hardness,sotUrock •pc,
` ❑Geothermal(Heating/Coolin.-Return) ❑Other(explain under.421/R'emarks) O g, /00 ft. 50
4.Date Well(s)Completed: O . a�' Well ID# AO " '7 [OO ft �/Q3' tr' 6f4yit .
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5a.'"Iell Location: Phone # ft. �!
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Facility/Oivn Name' ,Pvr v cilityID#(ifapplicable)
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Physical Address,City,and Zip
21.REMARKS
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Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell'field,one]at/long is sufficient) 22.Certification: M
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� / Signaturi of Ce ed Well:Contiactor Date
6.Is(are)the well(s): permanent or ❑Temporary -
� Bysigningthisform,thereby cer( that the ivell(s)iras(ivereJ"c11 onsnvcted in accotdonce a trh
7.Is this a repair to an existing well ,QYeS or : 'Q1Voj 73A NCAG 02C.0100 or 73A NCAC 02G1.0200 Well Consnvct ion,Standards and that o copy
lfthis is a repair,fill out knoiim well co»struclioii information and esploin the 1101ul of the of this record has been pros tded to the well owner.
repair under#2J remarks section or air the-back afihis forn'' 23.Site diagram or additional well detar Is:
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You may use the back of this page tli provide additional ivell construction info i
S.For Geoprobe/DPT or Closed,Loop Geothermal'Wells having the same (add'See Over'in Remarks$ox).Y Iu may also attach additional pages if necessary
construction,only I GW I is needed. Indicate TOTAL NUMBER ofwells `
drilled: 24.SUBMITTAL IIVSTRUCTIOD
9.Total well depth below land surface: Qo3 (ft') Submit this GW-1 within 30 days� well completion per the following:
For multiple wells list all depths if different(exoniple-3 t@200'and 2©100')
24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: /0 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
Bit Off: ri•V y�+ 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6, (in) Program,1636 MSC;Raleigh,NC 27699-1636 Alz
.12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Weirs:Copy to the
(i.e.auger,rotary,cable,direct pusb,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells yroducing ove• DQ060 GPD:Copy to DWR,CCPCUA
Permit Program,1 4 MSC,Raleigh,N 27699-161I _'
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Method oftest: 4� ' V�
4 t13a:Xield(gpm) s,
70%HTH l Amouist: Oz DATE SITE VISITED:
13b:Disinfection type: +`, N G V`���
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?4 t VISITED B- .: 1'���
North Carobna Department of Environmental Quality-Division of Water'Resources Revised 6-G-201 S
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