GW1-2022-00864_Well Construction - GW1_20220107

i
A OjQjSTR1(JC1 ION RECORD( -11 For.Internal Use Only:
1.v;dl Contractor information:
ViJD`F'f /rI S lA.WADER PANES
FROM TO 1 DTSCRBTION
WeDConhaatorgqName ft si ft. GPI
ft
NC Well Contactor cetifieanonNumber 15.OUTIdIt CASING for,niudti-cased webs)ORLWER rf a lirsble
YADK N WELL COMPANY,INC. FROM To DUMETER T>�csQVEss MATERrAL ®.
ft, ft in. MO
CompaayNeme 16:DUM CASING OR TUBWG eothermal closed-loop)
�. C11�'DnetlilctlolglPetIDlt#: FROM To I)MMMR TMaQgMS AUTMAi
M'sionapphcobte well conrtrurtion paPmAs(La.E#=County,State,Variance,ere) ' 5' it V in. 5�,�1 G
3.Well Use(checkweil use): S. in.
Water 6a Ir Weill 17:SCREEN
pp FROM TO DIAMEIZ+R SLDTSIZE TffiCIQVESS MATERIAL
OAgi cultura.I ❑Municipal/Publio ft.
❑Giotb;rural(HeatinglCooling Supply) esidential Water Supply(single) ft, in.
❑IndustrWCommercial [❑_Residential Water Supply(shared) 16.GROUT r
❑m anon ❑Wells>100,000 GPD FROM To AUTFMa EMpLACEMENTMETHOD&AMOUNT -4f
N6-Water Supply Well: ft' ft' po'-p.
❑Monitoring ORecovery ft 30 ft' (9 i}Ct6n:;6 Au
Injection Weli: ft g,
❑Aquifer Redmge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a livable
❑Aq uifer Storage and Recovery Malinity Barrior IRtOAR• To A7ATRRTAT" T MPLACrRM-NT METHOD
❑Aquifer Test ❑Stommater Drainage D
❑H"erimentel Terhnology bSubsidence,Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets ifnecessa
FROM TO DESCRIPTION color,hardness,soillmrk r nin sae,etc
©teothermal(Heatmg/Cool'mgRetum)' ❑Other(explain under#21Remaida), M y�
. R. ft 50®Q
4.Date Well(s)Completed: 01 '9 I`y Well ID# �-17 fL ],R'
:Sa.Well Location., Phone# -Ssa l ft.
ft ft
-�
Name F M# if ft ft
Faiati�y/Ciwars acility ( aPPli.Gable)
! ,t(eJ�
6 ft ft
Physio/el ®d Zip
0ft ft
� '21.REMARILS �y
ParcelIdent'r5cationNo.(PIN) JAN e 2021
County
' 5b.Latitude and longitude in degreeaWnutes/seconds or decimal degrees:
(ifwnll field,one brt%ugis sufficient) 22.Certification:
�i3 dC N gd- P-Wa-2 W lAJ e�riy a�
i 5igoatawd cjCerfifi4l Well Contractor: Date
t 6.Is.(are)thewell(s): Ptermanent or ❑Temporary
By signing thisform,:hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an eldsting well: ❑Yes or Awn 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Mandards and that a copy
t pis is a repalr,fdl out known well consbvct on lnforma[ion and explain the nature of the of this record has been provided to the well owner.
repair7mder#21 minarla section or onihe back elhisform. 23.Site diagram or additionalwell details:
You may use the back of this page to provide additional well construction info
S.For GeoprobellDPT or Closed-Loop Geothermal Wells having the some
eonsiruedot only I GW-1 is needed. Indicate TOTALNUMBBR of wells (add See Over'in Remarics Box).You may also attach additional pages if necessary,
drilled —b 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S4 2 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple we/is lisi all depths if different(emmple-3@J200'and 2Q7001
�,� 24a. For All Wells: Original form to Division of Water Resources (DWR),
1D.Statiewater level below top of casing: (ft) Information Processing Unit 1'617 MSC,Raleigh,NC 27699-1617
if water level Is above casing,use"+" f
11.13orehole diameter: _(in.) Bit Off: ' • 24b.For Injection Wells: Copy.to DWR,Underground In Control(IUC)
Prograin,1636 MSC,Raleigh,;NC 27699-1636
AIR ROTARY
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.'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
Permit Fmgram,1611 MSC,Raleigh,NC 27699-1611
13a:Yield(gpm) Method of test: ^r
13b.Disinfection type: 70c�"HTH Amount: a► OZ DATESITE VISITED:
VISITED BY: Q