GW1-2021-02396_Well Construction - GW1_20210722

Use onlv:
LAI FROM TO DESCRIPTION
Well Contractor Name
ft.
10P I
3' A 9 1 tft. 1
NC Well Contractor Certification Number nse ;,Ol 15.OUTER CASP(G(for multi-cased wllfOR LR(if apficabl YADKJN WELL COMPANY,INC, _F_R_0KT To DW-1 MiE:R I MATERIAL
IL ft.
Company Name I
16.INNER CASING ORT 6*TUBING thermal closed-loop)
2.Well Construction Permit#: 3 3 "7' FROM TO DLALIVIETER I TIUCI(NESS MTERML
List all applicable well construction permits(1-a UIC,County,Slate,1`47'10nce,etc.) 4pt. -13
3.Well Use(check well use): ft.
17.SCEffE 7z,N
Water Supply Well: FROM TO DWJETER SLOT SIZE THICIMESS NIATE L
DAgricultural 0Municipal/Public ft. fL in.
DGeothermal(Heating/Cooling Supply) bM-esidential Water Supply(single) ft. ft.
01ndustrfal/Commercial OResideatial Water Supply(shared) is.C-POUT
DIrrigation oWells>100,000 GPD FROM TO NVITERIA!, EP.IPLACM19t4T NMTE(OD a MKOUNT
Non Water Supply Well: 10 14 46*1 (fA*s/a I Qo"jo,ej
[]Monitoring DRecovery % 11-1ft. r
tr
Injection Well: A
DAquifer Recharge OGroundwater Remediation 19.&.Ulnt/GAPAVE L PA-C (if applicable)
[]Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL
DAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control
[]Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
DGeothermal 04eating/Cooling Return) 00ther(explain under#21 Remarks) IRON TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
- 0 ft- 12- 'L 1
4.Date Well(s)Completed: Well 1D# M"W'
ft.
5a.Well Location: Phone # ero�,j7 jj<-oo(; 70
04"'Imp
Facility/Owner Name Facility 1D#(if applicable) ft- ft. rf%It
C' ft
#yJ, it s lire f-k- 3 'S 4i
13 O
Physical Address,City,and ZIP ft. ft. all OkA_
21.REMARKS
oun Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
N W
6.1s(are)the well(i): permanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,Iherehy certify that the well(q)was(were)constructed in accordance with
Is this a repair to an existing well: OYes or 15A NCAC 02C.0100 or 15ANCACO2C.0100 Well Construction Standards and that a.copy
If this is a repair,Jill out known well construction information gdtloin 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:
You may use the back of this page to provide additional well construction info
8.For Geopiobe/DPT or Closed-Loop Geothermal Wells having the same p
construction,only I GW4 is neeJed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total w.ell depth below land Surface: 2a -(ft.) Submit this GW-1 within 30 days ofwill compl etion per the following:
For multiple wells list all depths ifdfferenl(e=iple-3@200'and 2@100D 40
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 MSCJ1 Raleigh,;NC 27699-1617
If water level is above casing,use"+
Bit Off: 24b.F Injection Wells:c to DWI
6 OIL or opy Underground Injectionbonfrol(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 276994636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loon,Geothermal Return Wells:Copy to the-
(ix,auger,rotaryi cable,direct push,etc-) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I '
24d.For Water Wells producing over 100,000 GPD:copy to DWR,CCPCUN
NC;27699-1611
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,
Oz DATE SITE VISITED.,
13b.Disinfection type: 70%HTH Amount:
5 P
VISITED BY:
Form GW 1 North Carolina Department of Environmental Quality-Division of Water Resources aA Revised 6-6-2018