GW1-2021-05309_Well Construction - GW1_20210615

i:ontiacior Own,
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NC Well Contractor Certification Number 0 " 15.OUTER CASING(for multi-rased wells)
'5rfl FROM T DiA.&YETER NUMMIN kil 271711MCI.211b�'ARIAL
yADI<IN WELL COMPANY,INC
Company Name
WSO 16.-TIqlvLE,R CASING OP.TUBING(geothermal closed-JODF))
T DlAPAETER FdATEPJA j,
2.IVell Co-.s-'­Ction-peinait#:
-,-3 + 5". 10 ft.
cabl,well constnictio"permits 6.e_(11C,C01117�11,State,T101-iance,etc.)
Gist 011 011171i _T1
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I 0D.40ni'Lorin- Ll ovir-tc Inrogi Pumped A t�2 SS
00roundv&ter Renledialioll
0Aquifer Storage and Recoven, 00'alinity Barrier TO NE1,Z
DAquifer Test oStormwater Drainage
oExperimental Technology 0subsidence Control
oGeothernial(Closed Loop) ElTracer 20.DII]IT-DIG LOG(attach additiodril sheets il'Decessary)
oGeothennal(Heating/Cooling Return) 00ther(explain under#21 Remarks) iR_0A1 _70--_ DESCRIPTION(color,hardness,soit/nrk e,min size,&c.
typ )
Is-ft-
d: Well IDN 4 gy rti V%
k 4.Date Well(s)Complete
ft.
5a.Well Location: Phone #_ZQ cL- 916 7013 ft.
ft.
-Ar�, 1 k rl-lvl+.e _ft. ft.
Facility/Owner Name Facility IDN(if applicable)
ft.
let,i S46,1,e Dr AIC
ft
ft. ft.
Physical AddressYity,and Zip
WA 4
21.RE,AiARICS
4 Ulm.
County w J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/mingies/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
N 3 .21 kiq W
Signature bfCcrtifibd Well Contractor Date
6.Is(are)the well(s): Wermauent or OTemporary By signing thisform,I hereby cerh)J,that the well(s)was(were)constructed in accordance with
.sting well: DYes or 0 15A NCAC 02C.0100 or 15A NC4C 02C.0200 Fifell Construction Standards and that a copy
7.Is this a repair to an em 'X ofthis record has been provided to the it"ell owner.
ythis is arepoir,fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form. 23.Site diagram or additional well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ^^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 days of well completion per the following:
For nIvIliple wells list all.depths ifdifferent(example-3@200'and 2@100') 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use Bit Off: St. 8sa 24b.For Injection Wells:Copy t:0 DWR, Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct 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,CCPCUA
I Permit Program,1611 MSC,Raleigh,!NU 2 IOYY-10 11
13a.Yield(gpm) Method of test: I Sr 4jr -
U 3
70%HTH Amount: Oz DATE SITE VISITED.-
13b.Disinfection type:
VISITED BY: Att Tf
Revised 6-6-2018
North Carolina Department ofEnvironmental Quality-Division ofWater Resources