GW1-2021-01464_Well Construction - GW1_20210305

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NC Well Contractor Czrtification Number F11 .y l��b" aS.OUTER CAST hG(fo,TtzU&U-1s:ells)OR,:LSI•TL'tea ar:pllesF Ee)
YADI<IIN WELL COMPANY,IPIC. -
Company Name
01 7S® Ec 1*1 HER R a AS I,G :7 3 U KrIG(�eatneMal cIased-lea,:)
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1i.:t oll applicable ell ccv7�:n-;!Ciia1 I ernliJS(i.e.(TIC',C'om7q,,SIPIe, E4u�inrrce,e1c,) —• 7L L
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❑,_gUL.i ..,�'e��-elid 1; CUe- I-I-'.IitoP,'Garriei I 1 � I1 77
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(I ❑„quifci Ies, V ❑Stonni:ater�ramage
OExoeriinenial Technology ❑Subsidence Control
❑Geotilenrral(Closed Loop) ❑Tracer 30.L.RF IMIG LOG raetaeh ndih-&F d sieels if n-cessnr;)
FSc+JIlg s� �?S!'RT:30id(rotor,F. rdness,soiUroeR r�pe,Emil size,etc.)
❑Ceotherzrizl(Healing/Cooling Return) ❑Oilier(explain under#21 Rellzarl:s) `9 it. t.a ft.
p� �oC f� 6� it. e`
4'�.Date Weli(s)Completed: ' �1 Well ID# A0— Cy e �a. _S 4-e,r►
5a.Well Location: Phone '-�' 334�- qS) q 7 5-0-a 4- r a
ft. ft.
L �>1�0,, L�tLA .
Facility/Owner Name
acility/OwmerName Facility ID4(if
ocAs -bC Vf
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Physical Address,�7i ,,and Zip
3fl.E?.ER•i����f5 i
aL� Ova -
t Parcel Identification No.(P
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification' / /
67,?6-7� ® �`� rob r d ITT F'li r� � / > l�' �d
Signatu—reoftYrtifiedlVell Contractor ! Date
.- - 11(s): T 'ermanent or ❑Temporary i
e By sio»ng!his fm m,l hereby cct lifi,11mF,the irell(s)was(mere)constructed in accordance with
7.Is this a repair to an a fisting well: ❑Yes or l0 15A AICAC 02C-0100 or 15A NCAC 02C.0200 Well Construction Standards and that o copy
If this is a repair,fill out larotvn well cansnvclion iJ7f0)a11a1i0n and explain the nature of the of this record has been provided to Ilia niell owner.
repair corder#21 renrarlrs section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/IIDPT or Closed-Loop Geothermal`Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GV1-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
4.Total well depth below land surface: 5-b l✓ (ft') Submit this GW-1 within 30 dayslof well completion per the following:
For mzdtiple wells list all depths if different(example-3Q200'and 3(a3100')
24a. For All Wells: Original form to Division of Water Resources (DR),
Ill.Static water level below top of casing: (ft•) Information Processing Unit,1617 MS W
C,Raleigh,NC 27699-1617
If ruler level is above casing,use
Bit pff. �d/�+ �� 246.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®penLoop Geothermal Return Wells:Copy to the
(i.e.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 GP1D:Copy to DWR,CCPCUA
e i Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ' Method of test: rt 8 r
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70°/ H T H OZ DATE SITE VISITED:
13b.1Disinfection type: ° Amount: i
VISITED BY:
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Form GXIVA !North Carolina Department of Emiromnenlal Quality-Division of Water Resources Revised 6-6-201 S
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Wilkes County 12/16/20�0 12': 45 : 56 PM PAGE 2/002 Fax Server
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