GW1-2021-00123_Well Construction - GW1_20211109

I;
Well Contractor Name FROM TO J IfTiC-0 f
ft. o• rt. f A4/1
a4sa it ft.
;
NC Well Contractor Certification Number '
15.OUTER CA_SWG for multi-rased wells OR LIIVER if a plicable
YADKW WELL COMPANY,INC. FROM TO nun�rcx TmcrwEss TMAL
ft. ft in.
Company Name 16.IlNNER CASING OR TUBING thermal dosed-loop)
2.Well Construction Permit#: (7 �✓ FROM TO I DraJ�01 TER THMENESS I 1dMA7TRrA7.
List all applicable well construction perTnits(te Comity Slate Variance,etc) ,�l 't -9, ft. G in. t v R a, P vC
3.Weil Use(check well txe): ft. ft in' J
D l R.5Cl'.rsPl
Water Supply Well:
Fe'Gi3 TO nU.rd?T'c.-A °LOTSIZE Tr71C14tESG i9AissP= .
❑Agicultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Fleating/Cooling Supply) residential Water Supply(single) it. g
❑Tndustrial/Comnercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrigation ❑Wells>100,000 GPD MON I TO W-TERIAL EMPLACErl•NT NET SGD L P1rIOUNT
.}.. Non-Water Supply Well: (t, ftDfle .ed, 3 1=,5S
� ❑Monitoring ❑Recovery 3 ft aL ft. Qv,G�;1-0 �v p
� lnsection Well: ft. ft.
CJ ❑Aquifer Recharge ❑Groundwater Remediation
C�
❑Aquifer Storage and Recovery gSalinity Barrierl9.SAVED/GP.AI'EL PACK(if applicable)
ier FROM TO MATERIAL I Err r_M.00M M OOD
❑Aquifer Test ❑Stormwster Drainage ft. & T�
[]Experimental Technology ❑Subsidence Control R. ft
�T* ❑Geothermal(Closed Loop) ❑TrSCer 20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Ifeating/Cooling Return) ❑Other(explain under#21 Rama s) 1rxo� To O DZsettrn-0ONl!or,ha,aaers salurnar s a cue
ft
9 4.Date Wells)Completed: Wei ID# 70 ft $iO ft GTGs,
13;F' 5a.Well Location: P�loll@ IFSf W'vl Cil� ft ft
rCt''R- S Y Jt.�'h 33 G �F6G._5130 ft.' ft.
f
' Facil tylOwner Naine Facil$y ID#(if applicable) fL %
r
Physical Addm`ss City,aad Zip ft ft t t ('-t hi
—,A '.(11 e r 21.RRMAR7tC �g
County Pored Identification No.(FIN)
Sb.Latitude-and longitude in degrees/minutes/seconds or decimal degrees: ( '
(ifweilfield,muleUlongissuffcied) 22 Certification
T rlc �l 'S q N T l .3 t W 4 ` ) e
Si ofC Certified ell Contactor Date
6.1s(are)the well(s): Permanent or ❑Temporary p
By signing thlsform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AD ISA NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standardr and that a wpy a
Ifthis is a repair,fd1 out(mown well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#11 remarks section Oran the barkofihisform. 23.Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may tine the back of this page to provide additional well construction too F ,
construction,only 1 CT I is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attacb additional pages ifnecessary
drilled: 24.'SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: S�y (ft)
For multiple wells list all depths tf different(example-3(a)100'and 2@100) Submit;this GW-1 within 30 days'of well completion per the following: l
24ii For All Wells: Original form to Division of Water Resources-.(DWR) „' q
10.Static water level below top of casing: Sa (ft) Iuforraation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use'+
11.Borehole diameter: ��(in.) Bit Off: 4.Des- 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
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
(it.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
s1V Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 12, Method of test: Q
70%HTH OZ DATE SITE VISITED: 6
136.Disinfection type: / Amount: ,
VISITED BY: !/ lf
ment of Environmental Quality-Division of Water Resources. Revised 6-6-2018