GW1-2021-05305_Well Construction - GW1_20210615

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Well Contractor Name 2 s ft. o,.1b A
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NC well Contractor Certification Number 15.OUTER CASING for multi-case d, ells)OR LINER(if applicable)
YADK19WELL COMPANY,INC. w1k,31 -iRo- DLAAIETER' I TEEICICNESS I MATERIAL
fit. ft.
& in.
Name 16.0NER CASING OR TUBING(geothermal dosed-loop) -4-
2.Well Construction Permit#: 13 EOM TO DIANIETER
List all applicable well construction permits(4 e.[HC,County,State,Variance,etc.) 4-1 ft- )Lf 1' If 0 2,1 P VG
ft. ft.
3.Well Use(check well use): 17.SCREE PF-
Wa',-cr Supply Weil: FROPI TO DIAP.-IETER SLOTSUE TMCKPIESS NIATEEE1
DAgricultural EiMunicipal/Public ft. ft.
EiGeothermal(I4-eatiingCooliilg Supply) e*esidential Water Supply(single) it. ft.
0I.industrial/Conimercial oResidential Water Supply(shared) 18.GROUT
DIrrigation oWells>100,000 GPD tD=TERL EP1-PLACEP-M-1-PIT NEETH OD.1, 1 P,,JOVJ4T
Non-Water Supply Well: D L4 2, 1 10J
DMonitoring oRecovery .6 v A o fill-
Injection Well:
0Aquifer Recharge oGroundwater Reinediation 19. E L PAC f if-1 P 01 c2 b I e 1
"'V
oAquifer Storage and Recovery oSalinity Barrier IN-1 I MATE- P.,1--rr4T HIM T HOD
. fL
0Aquifer Test OStormwater Drainage ft
[iExperimental Technology oSubsidence Control fL
DGeothermal(Closed Loop) oTracer 20.DRILLING LOG(attach additional sheets if necessary)
EiGeothermal(ileating/CoolingRetum) 0 Other(explain under#21 Remarks) fR-O51 TO DESCRIPTION(color,hardness,soil/rack t3rpi%grain size,etc
0 It. J/d
Well]OD# 'ekj 3Q-q5o poft.
4.Date Well(s)Completed:14-xf--�t _134 it R--"!!0 /'o
5a.Well Location: Phone # ft- 17? ft.
III ft- 11003ft- rvad
Facility/owner Name Facility ID# if applicable) ft. ft.
ft. ft.
'7
ft. &
Physical Address,City,and Zip
21.REKARKS
Conti), Parcel Identification No.(PIN) Frr. tL-,d 1 200 ?000
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong- is sufficient) 22.Certification:
N Y1 W
Signature of Certified Well Contractor Date
6.Is(are)the weH(s): oPermanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ClYes or BNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thaia copy c
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well;details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pagel1to provide additional well construction info,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
A
drilled: 24.SUBMITTAL INSTRUCTIONS
9.,Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) Bit Off: 24b.For Injection Wells:Copy tqDWR,Underground Injection Control(EUC)
Program,1636 MSC,Raleigh,NC 2 7699-1636
12.Well construction method: AIR ROTARY on For Water Supply nd Open-Loop Geothermal Return Wells:
:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where m0ed
FOR WATER SUPPLY LLS ONLY: 24d.For Water Wells producing I e I r 100,000 GPD:Copy to DWR,CCPCUA
Permit Program.,1611 MSC,Raleigh,I�IU27699-1611
13a.Yield(gpin) Method of test:
70%HTH 0 Oz DATE SITE VISITED:
13b.Disinfection type: Amount: 45.4 - A
VISITED BY:
Form dW-1
North Carolina Department ofEnv"nmental Quality-Division of Water Resources Revised6-6-2018
D,