GW1-2021-06277_Well Construction - GW1_20210915

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WELL CONS 1TRN1C I I,,DN RECORD MW-11 For Internal Use Only:
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1.Weil Contractor Information,
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Well Contractor Name rRam To DESCR21MON
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLDIA—A of a -ble
YApKIN WELL COMPANY,INC. FROM T® 1AMTER TWClagESS iK&TERML
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Company Name 16.WNTR CASING OR Tl1BUgG othesmal closed-loop)
.�' FRolta To Dr rER TMCKR7F.55 EM MAL
2.Well Construction Permit#: ��'���•.,�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 41 • �� °n' Da- Pic
3.Well Use(check well use): ft` ft. t®
17.SCRM _
Water Supply Well: FROM To DIANE= SLOT SM TIlIMMS I HATE.AL
❑Agricultural ❑Municipal/Public ft. ft. 1®•
❑Geothermal(Heating/Cooling Supply) Otesidential Water Supply(single) ft. ft. 1®,
❑lndustrial/Commercial ❑Residential Water Supply(shared) it GROUF
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❑Irrigation . ❑Wells>100,000 GPD FROM TO INATERYAL EWMLACEilr MT RMEOD ArdQU T
Non-Water Supply Well: fft. ft. B�`��
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❑Monitoring ❑Recovery fL 8y9 fL (M A& . Pt 4
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation U.SAMIG AVELPACl (ifa lipW
❑Aquifer Storage and Recovery ❑Salinity Barrier FRord :To it�Tl iRI. EI�LAC9=Ws a'F3oD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control &
❑Geothermal(Closed Loop) ❑Tracer 20.DPJLL 4G LOG attaelt addit otisd sheet necesimUl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadts) FROM . To � DESCRIPT1011 coloe bards saiffliacktMe,gmia skie,etc
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4.Date Well(s)Completed: �� � � Well_EM 521 c,
5a phone #Well Location: ,? d��
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Facility/Owner N ee I� Facility M#,(9if applicable)
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Physical Address,City,and Zip
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County Parcel identification No.CM
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lablongis sufficient) 22.Certification.
6.Is(are)the well(s):J ermanent or ❑Temporary Signa*e of " ed Well Contractor Date
By signing thlsform,I hereby certify that the we11(s)was(were)constructed in accondmme rwlth
7.Is this a repair to an existing well: ❑yes or 0 15A MCAC 02C.0100 or t5A NCAC 02C.0200 Well Construction Stmtdan*and that a copy
If this is a repair,fill out blown well construction information 8nd explain the nature of the 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 vwell dettalls:
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same you may use the back of this page to provide additional well conatruclion info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in ltematks Box).You may also attach additional pages if necessary ^�°
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drilled: a 26.Mb=AL INSMIITC1r ONS, 1-11
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9.Total well depth below land surface: svabanit this QRFFJ-1 asnth➢mm 30 dais of well completion per the 4ollovvlDg:
For multiple wells list all depths if different(example-3@200'and 2 a@100) I
24a. For All Wells: Original fnrre to Division of itchier Resources (DWR),
10,Static water level below top of casing: (ft•} Information Processing Unk 1617 R93C,Raleigh,NC 27699-1617
Ifwater level is above casing use
/ } Big Ogg: S'�9q' 2Aib.Yor Ig ction Wells:Copy to iDWR,'Underground Injection Control(tUC)
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11.Borehole diameter: _fir rn• Program,1636 MSG,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Otte l-Loop Geothermal Return Wells:Copy to the 1
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county there installed r,.
FOR WATER SUPPLY WELLS ON'iLY: 24d.For Water Wells producing over 100,000 GM Copy to DWR,CCPCUA
C4 G% Penult Frog mxn,1611 MSG,Raleigh,NC 27699-1611
13a.Yield(gpm) lbtethod of test: `
70%HTH ( i DATE SiTS VISITED: yip
13b.Disinfection Amount � u EOZ
_ i1ls1TEf3l�Y: Ili