GW1-2021-02607_Well Construction - GW1_20210809

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Wdl Contractor Name r LOCI TO DISC. •Ti011
64 11- yZ
`3 /a MCI ft 19 z fL c2 E
NC Well Contractor Certification Nimbus 15.OUTER CrSSIATG far multi dwells OR LINER if a livable
YADION WELL COMPANY,INC. FROM TO DMAKETER ss TERIAL
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Company Name 4 1G.IIVATF.RCt1SIAGORTUBWG � othermaldased-lac l`r]
2.Well Construction Permit#: WEB L —10 d 40 14 v ��3 a�' FROM To I DIp 4II TER muca ss MATTEMAL - 1
List all applicable well construction permlts(I e.UIC,County,State TImIance,eta) & V- fr. 6,r/ 1°' '�a $�'" 6 V S'l 4
3.Well Use(chec€c weil r,se): fr• ft. in. �, IM` .sAO r n
Water Supply Well: 17.SCRE2N v
rrori TO DU_NETER I SLOTSUF I TMrT(7irss I r:�-'rrtIAL
❑Agricultural ❑Municipd/Public
❑Geothermal(Heating/Cooling Supply) eVesidential Water Supply(single)
et. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 11.GROUT
OIrrigation ❑Wells>100,000GPD mold TO t3 MRL?� EMPLACEMENT .ETBODrsal:•iotmr
Non-Water Supply Well: tl. - ft
22476C 6 �AV e�
❑Monitoring ❑Recovery 3 ft a 7 fr, ���V �f
Injection Well: fr• ft.
/
❑Aquifer Recharge ❑Groundwater Remcdiation
r
❑Aquifer Storage and Recovery ❑Salinity Barrier19.SA D/GP.A1'F,-PA (d'ap,ticable Mid To I MATIMIAL liT4Yr1 til31 thtTMETHOD r
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft J
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal eatin Coolie Rrtum ❑Other IWAI TO DRSCRVnON color,hardness soil/rack a'vr,etc
g/ g ) (explain under#21 Remarks)
9 q A,, o & ft. S' G
4.Date Well(s)Completed: �d �l Well IO # A/7iJ— .r,6 V 'q fLI kf fr Cl s°'
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5a.Well Location: Phone # 1D—Q;—*3" /& fL G fL [►�1/li .��rd R.�
KG�in �u¢aks ft- 2Z G ' 1;k�
Facility/Owner Name ft.FacilityID#11(ifapplieable)
ft
3`7HN �uc�E • &J ad CAlAwba
Physical
Address,City aidft
Zip ? q fL
V AL Ili( .4' 37
G% 3V3.274-12 7
County Parcel Identification No.(PIN) ruil' er+ne st /w
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: F
(1well field,one lat/long is sufficient) 22.Certification: \C
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6.Is(are)the well(s): Permanent or ❑Temporary Siw-tune of Certified Well Con tar Darc
Bysignbrg thisform,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eristing well: 7 ❑Yes or 8No 15A NCAC 02C.0100 or 1 SA NClC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill aul7orown well construction information and ezplatn the nature of the of 0+o record has beenprovided to the well owner.
repairunder 921 remarkrsedion oron the backofthisfonn. 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 Remarlm Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z 2- (ft
For multiple wells list all depths rfdifjere u(=onple-3@200'and 2©1001 ) Submit this GW-1 within 30 days!ofwell completion per the following:
S� 24a. For All Wells: Original form to Division of Water Resources (DWR),
fi Static water level below top of casing: A) Information Processing Unit 1617 MSC,Raleigh,If water level it above casing,use"+" g t,° NC 27699-1617
6
11.Borehole diameter: (in.) Bit Off S,R/ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12 Well construction method: 4 myj � f> 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
(i.e.anger,rotary,cable,direct push,etc.) county environmental health department of the county where installed .
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing I ver 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) I Method of test: t at P�'t�o��'1611 MSC,Raleigh,NC 27699-1611
G fRV tO 49,
1 -I�r
13b.Disinfection type: 70%HTH Amount: AJ OZ DATE SITE VISITED: l ' J a
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Md .}°rAt VISITED BY: foo I PD
Form OW-1 _ North Carolina Department of Environmental Quality-Division of Water Resources, A Revised 6-6-701 a