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HomeMy WebLinkAboutGW1-2021-07102_Well Construction - GW1_20210915 7. �•-'-.--�..� �. .�`/ (, �� FR1,.I TO DESCRIPTIOrl Well Contractor Name V �x L(9 ,A ^A r���.. .,Cn mot. ic"tt. r NC Well Contractor Certification Number �� ,+t?N `, 4,r�h• 0 15.OUTER CASING for multi-cased iv OR LINER it ap licable YADI<IN WELL COMPANY,INC. FROM To DrAMETER T1�cICNEss mtATeRUL pp Ft. ft. ! in. Company Name G� CIL 2 2 6 Z 6 J / 16.INNER CASING OR TUBING eothermal closed-loo ) Z.Weil CDnstr'aCtiOe Permit#:7-73 5'-ZO FROM TO DIAMETER TffiCHMSS MATERIAL List a//applicable well canstn ction permits(i_e.UIC,Cannty,State, 11ariance,etc.) ft. 3.Wei 11 r o\• it. fi, in. v 17.SCIrFEi1 / n ;yatet S??o:•,a(te; ��� C. I - y - , 7;_r,:. !Vf '� 1 1::C'1:1 — N T_f'. -LOT JL_ :i��CrJ IL'-J 1.... — VA^ rLdWM II ❑Rtluniaipal/Publir ❑Geothermal(Heating/Cooling Si;pply) ❑Residential Water Supply(single) ❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT ❑Irrigation ❑Wells> 100.000 GPD FROM TO r.1TZPV%iL EhIPL?CEnrENT METP_nD 1:V,1OUPIT 1'1e13-11t2,er Saapply Well: � O — tt. l-t C iN re it ❑Monitoring ^�- ❑Recovery ft. rr. C 6%Ir V Injection Well: — ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.St>sllD/GRA'!EL PdCIri(if applicable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FRORI TO I:•IATEMAL EMPLACEi:IENT NI TROD ❑Aquifer Test ❑Stormwater Drainage ft• 'T ❑Experimental Technology ❑Subsidence Control ft. ft. ❑Geotherriial(Closed Ltjop)4' ❑Tracer 20.DRILLING LOG attach additional sheets if necessa FROM TO DESCRIPTION color,hardness,soithmck typ4 gnin sae,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � t0 ft- ft. Gt 4.Date Well(s)Completed: -3 —oN Well im �� 3 +e ft' k' -rh 4 Mon Sa.Well Location: Phone # ,11 M ft. le r 1'4i le Fa�ty/Owner Name Facility ID#(if applicable) IM CIrP4k RA 6' ft fr. lcii wr r c SG y c Physical Address,City,and Zip ft. ft. 21.RE MARKS 7 County 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: 36` /-.-/A 7C� N k 3 f` W 6.Is(are)the well(s): @Permanent or ❑Temporary Signature of Certified Well Contractor ! Date By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance with yy(\ 7.Is this a repair to an eadsting well: ❑Yes or 971Vo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WM Construction Standards and Thal a copy J If this is a repair,fill out known well construction information and explain the nature ofihe 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 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: / 1` 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: w sir+ (ft.) Submit this GW-1 within 30 daysof well completion per the following: For multiple wells list all depths If different(example-3 r@200'and 2@100') (� 24a. For All Wells: Original forIm'.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: Q f 0 24b. For Injection Wells:Copy to II 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 departinent of the county where installed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing!over IKAO GPD:Copy to DWR,CCPCUA Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) Method of test: 70%HTH OZ DATE SITE VISITED: ('12I' Z OW 13b.Disinfection type: Amount: - A VISITED BY: � G 9 rY Rnrm GW-1 _ North Carolina De rtment Environmental Quality-Division of Water Resources �� Revised 6-6-2018