GW1-2021-06310_Well Construction - GW1_20210915

well ConttactorN w 4 er:Ot1 ^t) i G sCi iLOii
NC well Contractor'Ce&ctation Number 15.OUTER CASING for taut6-cased wells OR LU4ER if a ticable G�
YADION WELL.COMPANY,INC. FROId To DIAA��'C�TER MCIQ�Css 4ATEMAL
ft.. ft i IfL
CompattyName We � IG,l2II4ER CA BihG OR TUBING!( -athernial dosed-loop)
2.Well Construction Permit# .q. 40—� '06�2� FROM To DIA.nn;TRR TmCrt MSS MATERIAL
List all applicable well construction permits ae.EIIC,Cmmty,State,Variance,eta.) ft. :51'97 , Ily-far iu. i e-
3.Well Use(check well rise): fl. ft. 1rL �
17.3Cr1=t PI
@crater SngDply +eEl6 _ F-P.0 AO ov_t"l: s T r� { '
_Ted LOT SIZ TOCICHESS I:7 !L111.1,L
QAgr3culiural Cl unicipal/Public ft. ft. In.
QGeothemial(1leatineCooling Supply) residential Water Supply(single) it. In.
Olpdustrial/Cohnnercial OResidential Water Supply(shared) 11 GROUT
Qirrigation OWells>100,000 GPD MOM TO MATERIAL arrrt,ACEI ANT PETOOD&AJ.10UNT
Non-Wateir Supply Well: O f I. ft.
[]Monitoring ORecovery, ft ft
)biseetioae Well, ft.
-S� E
ft. ft
QAquifer Recharge QGroundwater Remediation
19.SASTOtCaI'A'VE, PACK(if applicable)
QAquifer Storage and Recovery OSalinity Barrier FROM TO MATUML I ERPLACIELM4T A•G—HOD
OAquifer Test QStarmwater Drainage
ft fr.
OExperimaital Technology QSubsidence Control ft fr.
QGeothertnal-(Closed Loop) QTracer 20. DRLEL]NGLOG attach additional sheets if necessary)
'?ROD' TQ DESCRIPTION(color,hardness,sall/radc e, 'n sva,eta
OGeothermal(tieatingJCoolulg Retiu'is)` QOthe;(explain under#21 Remarks} /
ft. V/ ft De p fg6rt
4.Date Well(s)Completedc '-/ Well E D# fr AW ft eol ti Arne/ 600`
S WeH Locatlon: Phone `eta �' ft ft
a.
Faralttyl0 Name Faabty M#(if applicable) ft. fr.
t$¢�®
PhysicalAdthess.CM and dip
�° (( 21.REM,APM
County Iiareel Identificat on No.(PIN}
5b.Latitude and iong�tude,in degrees/minutes/seconds or decimal degrees: p
(lfwellfield,im:Idnongis svffmient) 22.Certification:le q�
O
12
6.Is(are)the well(s): ecimanent o"r OTemporary Si of ed Well antractnr Date
By signing this form,!hereby certify that the well(&)was(were)constructed in accordance with$
7.Is this it repair to an existing well: QYes or Wh!o 15A NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
tfthis is o rrpair,fdl outbtown well construction information and explain the nature of the of this record has been provided to the well owner,
repair under i121 r amar/s seatiatrorrni the backafthisform.
23.Site diagram or additional well details:
$ For GeoprohelDPT or Closed-!,bop 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 TOTALNUMBER of wells {add See Aver in Remarks BoX).You may also attach additional pages if necessary.
dn7led 0 74.SUMMAL JNSTRUCTIONS• f
9.Total well depth below land surface:
ll depths f djjererrt (ft) Submit this GW-1 within 30 days of well completion per fire following: i
Formultiple wells llst.a (ermuple-9 a0200-and 2@1001
3 e 24a. For All Wells:.Original form to Division of Water Resources (DWR),
10.Static wafer level below top.of easing (ft) Information Processing Unit,161714SC,Raleigh,NC 27699-1617 t
Ifwater level It oba4 casbtg,icre"+
Bit Off: S.% 0 24b.For Injection Wells:Copy to1DWR,Underground Injection Control(IUC)
11.Borehole diameter (in.) Program,1636 MSC,Raleigh,NC 27699-1636
X2.Well construction method:. AIR ROTARY 24c.For Water Supply and Open-Lon Geothermal eothermal Return Wells:Copy to the
(i.e.anger,rotray.cable,+lueet ji4 dte•) county environmental health department of the coimty where installed
FOR WATER SUPPLY WTM ONLY: 24d.For Water Wells producing aver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test: ,
?I1%HTN t 7 DATE SITE VISITED: �� �0 "
13b.Disinfection type: Amount: ®2
VISITED BY:
F�GW 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised b-IZ,2 8