GW1-2021-07102_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