GW1-2021-02341_Well Construction - GW1_20210722

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Well Contractor Name TJ' - !R0P.I :O LZST='`l i0i i
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3 3 ,, 2021 r'70 fr. l-7 ft
NC Well Contractor Certification Number ,,�It_ is.OUTER CASING for multi sedtvelis ORLINLrR ifa livable
YAGKIN WELL COMPANY,INC. ROt;(3SS�B�ud" FROM To Dw:o TER THICICNEss TERIAL
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Company Name ��O DIN,Z t0R CASYNG ORTUBING(geathermal dosed-loop)
2.Well Construction Permit#:_ f / FROM To DIFINETER T UMNESS MATERIAL
List all applicable well construction permits(re.UDC,County,State.Variance,eta) ft- in. 64
3.Well Use(check well use): fr. ft in. ,t L
l7.SCr_T,'Z f
Water Supply Well: Fa Orrl TO DIArA TEPI SLOT SIZE THICICH SS AIAT-arusL
❑Agricultural ❑MunicipalRublic ft.
❑Geothermal(Neating/Cooliug Supply) residential Water Supply(single) fr
❑Tndustrial/Commercial ❑Residential Water Supply(shared) ice.GROUT
❑Irrigation ❑Wells>100,000 GPD MON To KATERIAL EMPLACEMENT P.•TTHOD c AtrlOnj T
Non-Water Supply Well: f''
❑Monitoring ❑Recovery 3 It. q3 ft. ;iRt rrN U91
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRA1 L PACIC(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bar,ier FROM To MATERIAL EeiPLACSrirNTMETHOD
❑Aquifer Test ❑Stormwater Drainage fr fL
[]Experimental Technology ❑Subsidence Control ft.
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(IIeating/Cooling Return) ❑Other(explain under 421 Remarks) rRonf To DESCRIPTION roles haranea:,se;uredc a a sae eta
� fr. 3 ft.
4.Date Well(s)Completed: (�J'2 3-21 Well m �0- 2 b/ .3 fr' 19 fr (46 6
5a.Well Location: Phone # 33�-9�y78$� `�61 fr
Face y/O Name Facility ID#(if applicable) ft. ft.
ICS. G 1 Z dAj 1 , r". % fr.
Physical Adds ss,City,and Zip .2 U29 � ft
SQ_ 21.RRMARTCR
County Parcel Identification No.(Mo ,'^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:39 " 21 to? b N ty 3 ° ll" w
6.Is(are)the well(s). Permanent or ❑Temporary
Sil rah_=of Certified Well Conhactor Date
By signing thisfonn,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Po 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is o repair,fill out!mown well construction information wFirarplain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
`depths ird fferent(example-3@200'and 2(a)l00� Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all
�^ 24a. For All Wells: Original form to Division of Water Resources (DWR),
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10.Static water level below top of casing: 0 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
;fwater level is above cas4irrg,use"+" n
Bit Off: s° 17$ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: Cn) Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction.method: 24c.For Water Supply and OpeniLoop Geothermal Return Wells:Copy to the
(i-e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD:Copy to DWR,CCPCUA
! Permit Program,1611 MSC,Raleigb,NC 27699-1611
13a.Yield(gpm) 71 Method of test: 4qt r fi i
70/o
o HTH OZ
!� DATE SITE VISITED: r i
13b.Disinfection type: Amount:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources;' // Revised 6.6-2018
DO i r c .416, h