GW1-2021-00973_Well Construction - GW1_20210415

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NC Well Contractor Certification Nwnber q p;) 2021 15.OUTER CASING for r+ulti-cased s,ells)OR LFIVCR(if applicable
`(ADKIN WELL COMPANY,INC. APR FP01'I TO DIr1114ETEFt T�CI:NESS I TEItIr1L
ft. ft. III.
Company Name Irlformatten
4 r �r��Cvection 16.INNER CASING OR TUBING eotherraal closed-loop)
t�+ FROM TO -DIAMETER TffiCISPIESS r.•IATERLIL
2.Well�Constructaon Perr!eit#:
List all applicable well construction penults(i.e.UIC,Cornq,,Stale,flariance,etc.) ft. a(/' ft, 1�n S•D 7 ���
..d�Jei�i'Js_ T, c';;-;-.Fie : •_)•
❑ _ .grtil i Lin!! ❑I✓1!!iit�ihal/Fl?blip I I ( �_
0Geatltc:_133a1(1-1e,ting/Coolill Supply) ❑Residential GVaier Supply(s!nSle) ;?
❑fndusirial/Contmercia! ❑Residential Rlate Supply(shared) 1d CR;r_.aiT
01rigation ❑-Wells> 100,000 GPD _ROH To r:LA721FI. I =rI?,._TENZHT isI=_TFOD=•rUIO ANT
H0T:,-5rdr y ire?ac f7 t. (a' rn CI1• , I �tr 1
❑Nlonitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Reniediation 19. PACK(ir o fpllthle)
❑Aquifer Storage and RecoveiY ❑Salinity Barrier FROM TO HATEPf�L El1•a-eLAU-.LENT RIETHOD -�
❑Aquifer Test ❑Stormwater Drainage f<• fr.
❑Experimental Teclueology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock typc,_ruin size,etc.)
❑GeoUlermal(Heating/Cooling Return) ❑Other(explain/under#21 Remarks) O ft �' 'ft So;4-
4.Date Well(s)Completed: .Z'7 a�'r7i Well ID# (� U- 10 75— s' sv •�►�.f�
n ft.
5a.Well Location: P{-;one #�Q(9_ Z - S`l�J.� �k0 ft. Wo �e f
Y c '7 3 o ft. Q ft. Ps/
Facility/Owner Name h '(��/O.^ Facility IIDA(if applicable)
N4t "v L ��V �' 4 ft. ft.
Physical Address,City:and Zip ft.
( �� PC-
1ARKS r
County 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
6.Is(are)the;veil(s): CPermanent or ❑Tem Si are of Ceed Well Contractor Date
porary ;
By signing this form,I hereby certi)5,that the well(s)was(were)constnrcted in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well constrvctfon information and explain the nature of the of this record has been provided to the well owner:
repair under 921 remarks section or on the back of this farm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells leaving 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 Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5a (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3Q200'and 2 r@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: /Oy (ft.) Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
Ifrvater level is above casing,use"+"
Bit Off: .Jos 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop 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 GPD:Copy to DWR,CCPCUA
Y Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �' Method of test: �i�
o / D:
13b.Disinfection type: 70/o HTH Amount: / a— OZ DATE SITE VISITED:
VISITED BY:
Pr•i t^P' y' "
Form GW-1 North Carolina Department ofEnvironrnental Quality-Division of Water Resources Revised 6-6-2018
l ` _ .I 1C Senn N2