GW1-2022-08578_Well Construction - GW1_20220408

well C:ontrncior Panic gJ5.0UT$FRCASING
// i;. 1 pR Yy'- ft. _ .__NC Well Contractor Certification Number (for©ulti-r�sedlmvells)ORLUCiR(iiapplicable)1'ADI<Ih!VIrLL COMPANY,INC. O DL41 TAR T FICi ICss MATERIAL
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Company Name �/ ^ 16.IANEP.CASING OR TUBING:( eo'hermal closed-loo
- 0 1 LI 3o O - d��� FRor.I To DIATIETCR THICKNESS r:2ATEPi?L G
2.Well Cor:struction PeFrnit#: �A/�
list oll applicable u+cll conduction permits Ae.111C,CO)'" Shale,Pori 1 cc elc.) + J LEI y
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❑1+iC:,i�::ev _u +_i.+ ❑1'.: =iitl I I,fl, t.: i! l iJ. :52<'u,-: -
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Oiler--`1`diu;'----.-
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❑3roundii'ater Rri-11cdiL10111 _:. cia!:'Lr.C=i:;eN!
❑Aquifer Storage and Recovery ❑Salinity Barrier s'�FC�i:; To e;::T _c_� -
❑Aquifer Test
❑Stomiwater Drainage tt'
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DR LLING LOG(attach additional sheets if necssarr�
FROM TO DESCRIPTION(cator,hardness,snsurodc ripe,enin size,cte)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) ©• fi. *q ft. so;r /
-.2a Well S ft. �1y0 ft. soA r
4.]Date Well(s)Completed: e
5a.Well Location: Phone #_ j4- 7�d_ 8 7�Z ��O ft k4 f t t (Ir.^:
Lam,_," I -SA in"lA 14 J;6 7y.E- /ZQ/
Facility+/Owner Name
Facility ID#(if applicable) ft. ft.
WSJ 3 W, d!�/ ���A ft. ft. APR o2�
fr. fr.
P]Iysic-al Address,City,and Zip Yam ),,•,,
� 21.R1✓A3AlZIfS
county Parcel Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification'
360 110? i N kno s 79IS-a _W 3-a?.f=2Z
Signature of Certified Well Contractor Date
6.Fs(are)thewell(s): ermanent or ❑Temporary
Bl+signing Ihisfotnt,]hereby cert)5,Thai the a+ell(s)was(here)carslnrcted in accordance wilt
7.Is ibis a repair'to an existing well: ❑Yes or �io 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that o copy
If this is a repair,fill out known Well constn,ction information mid explain the nature of the of this record has been provided to the well ou+net.
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 ivell construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of vvells
drilled: 24.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 38� (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if differew(example-3@200'mud 2©100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: S V (fti) Information Processing Unit,1617''MSC,Raleigh,NC 27699 1617
If water level is above casing,use"+"
Bit Off: s. U 24b.For Infection 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 Ope i-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct pusb,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
1�0 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:ti' AL
P�
70%HTH Amount: OZ
DATE SITE VISITED: �`
13b.Disinfection type:
VISITED BY:
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
Form GW-1
job,