GW1-2021-05268_Well Construction - GW1_20210503

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Well Contractor Name ft. ft.
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NC Well Contractor Certification Number MAX X 15.OUTER CASIK 7G for ulti-ebseAells)?LL Rfifapplicable)
TolMrUS _1FROM TO DIAMETER ss RATEPDE
YADKJN WELL COMPANY,INC. _ram -A,*,,,)n 01 n ft. in.
AWR se�clloil
Company Name W i I",J :1 A&_ C S-1 16.1114NER CASING OR T DIG(Reothermal dosed-loop)
2.Well Construction Permit#: 6 2 / S— FROM I TO I DIAUVIE-TER I THIC104ESS MATERIAL
List all applicable well construction permits(i.e.&7C,County,State, Variance,etc.) ft- I 6q ft- 16, 1,�f'n- 10t4UI I /a VC-
3.Well Use(check well use): ft. ft. in.
8 C RE 7
Water Supply Well: F-17.ROR] N
TO DLAPIETEU SLOT SIZE THiCHWESS I PJATEFLIAL
DAgricultural CIMunicipal/Public ft. ft.
H,•
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) It. it hm
01ndustrial/Commercial DResideritial Water Supply(shared) 13.GROUT
olrrigation oWells>100,000 GPD rRoil I TO RP-TERIAL _VM?LACEr=,i I D-17 THOD&AMOINIT
Non-Water Supply Weli: "el i
ElMonitorin- DRecovery L4 �)k"),A
injection Well: ft. ft. 1
0Aquifer Recharge ❑DGroundwater Remediation 19.SAPIDIGPUAYEL PACK(1:applicable)
DAquifer Storage and Recovery oSalinity Barrier FROM TO iYIATLRIAi ERIPLACEPEE r4T rM THOD
DAquifer Test oStormwater Drainage
DExperimental Technology OSubsidence Control
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) TROA-1 TO DrSCREPTION r-
(color,hardness,soil/rock type�Zrain size,et )
a ft. 3s- ft. �so,v
4.Date Well(s)Completed: Lt'Q—*I(we,,iD# A4P- L13 Sr 75-ft- i,s ft q'C"k'q
_Q Sa.WeU Location: Phone # %:), sat
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Facility/Owner Name Facility M#(if applicable)
ft.
?S4 Red, lu A, I-- at 6L4 a—
Physical Address,City,and Zip ft. ft.
25 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification-
N 5-9, .5"8' 5-�z W
C H —
Signature of Certified Well Contractor 6.Is(are)the well(s): ��ermanent or OTemporary i ' Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or XNO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
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 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: 361k
—(ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100D
140' 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
Ifwater level is above casing,use"+" i
11.Borehole diameter- (in-) Bit Off: j6 0 24b.For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC.27699-1636 .
12.Well construction method: AIR ROTARY on For Water Supply and 0 A-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health dep I artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells vroducing over 100,000 GPD:Copy to DWR,CCPCUA
-C 6t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)_'5 ) Method of test.
70%HTH 0z DATE SITE VISITED:
13b.Disinfection type: Amount:
C' Poffj VISITED BY: Iz
Form GW_1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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