GW1-2021-02776_Well Construction - GW1_20210809

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me FROM TO DVXWTi0H
57411- " '3m
30 ft. 3,03ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cas ells)OR LIFTER if applicable)
FROM 1 TO 1 DLAACTER THICICNEsg I MATERIALYADKIN WELL COMPANY,INC. I
ft. ft. in.
Y\
Company Name
C edt
0 16.INNER.CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit FROM TO DIAMETER THICKNESS MA-.111 AT•
List all applicable well construclionpirmits(i.e.UIC,Minty,State,Variance,etc.) tl ft. ft. in.
, I
3.Well Use(check WCH Else): ft. ft in.
17.SCIU,Zi N
Water Supply Well: FROPI TO DI<.nirT3R I SLOT SIZE i THiC113-1ESS 2A.T E PD.L
DAgricultural oMunicipaUPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply)
�tesidential Water Supply(single) it, ft. in.,
01ndustrial/Commercial DResi.dential Water Supply(shared) I&CmOUT
DIrrigation DWells>100,000 GPD F1110i'd TO NIATE-W-L EPUPLACEP-M,HT METHOD a,AlvIOUPIT
Non-Water Supply Well: 0 ft. 3- ft. ee-4�je a t'10,5 rOVee,"
0monitoring DRecovery
Injection Well: ft. ft.
OAquifer Recharge EIGroundwater Reiriediation 19.SAND/GP AVE L PACK(if applica ble)
DAquifer Storage and Recovery oSalinity Barrier FROM TO IVIATEWL
DAquifer Test OStormwater Drainage
oExperimental Technology OSubsidence Control
oGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
rROA1 TO DESCRIPTION(color,h.�dness,saillrock type�grain size,etc.)
oGeothermal(Ileating/Cooling Return) ElOther(explain under#21 Remarks) y ft- t7 ft' I r
4.Date Wells)Completed: v ~ Well ID#A4 7
5a.Well Location: Phone # Lay w2riq-/5-,V Fr 'yf t -14-
4r ILI - ""f m-0" 0� 'bV4 Il e
krl5 ( 1,&AChi ft. a� O ICe - e
Facility/Owner
Name Facility M#(if applicable) 2 5-ft- 51 ft. -ell t'A y M/ 41'4
5-1
Physical Addresitrky,and Zip
out ft-
21.REMARKS
C6unty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N 91 r7
6.Is(are)the well(s): Itermanent or OTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(q)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or TO 15A NCAC 02C.0100 or 15A NCAC 02C.6200 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 I 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: I -
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
(ft) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ffdifferent(example-3@200'and 2@100)
. j Irk 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: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter; (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open`LoopGeothermal Return Wells:Copy to the
(ie.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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 101 Method of test:
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:
VISITED BY:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018