GW1-2021-02771_Well Construction - GW1_20210809

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ell 11tractorName FROU TO
3034A a , '(1\0 110 It T&S-
RC Well Contractor Certification Number 15.OUTER CASING(for idti-casedVIs)PLINER. if ble)
YADKJN WELL COMPANY,INC. TO FROAS I sge— DLOCM-R 71M TERIAL
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Company Name 1&0;�tn
16.DUqER CASING OR (geo 21 dosed-loop)
2.Well Cenitruction Permit AL-r 3 FROM TO DIADMiM _ MUMMS I MATERTAL
List all applicable well construction permits rLe.LUC,County,State,Variance,etc.) IL /10 ft- 6SIX in. 01 4& 1641. s
3.Well Use(checEL well u.se): ft. ft in.
SCPZ,
Water Supply Well: 39.FROT"i 2N TO DWiFT ER STLOT SIZE lo P.TfflcfEss i Tcs-L,r,
DAgricultural oMunicipdlPublic ft. ft. in.
...........................
oGeothermal(Heating/Cooling Supply) residential Water Supply(single)
111ndustrial/Commercial oResidential Water Supply(shared) I.GROUT
01rrigation D'Oells>100,000 GPD MORI I TO HATE-TUAL EMPLACEr.Xi NT P.-JETHOD c AMOUNT
Non-Water Supply Well: It A' "'7k a—.,
DMonitoring IlRecovery 3 'L "- ,&4
Injection Weil: _1 I"
ft &
oAquifer Recharge CGroundwater Rernediation 19.SA1104GRAIT,L PACK(if applicable)
0Aquifer Storage and Recovery oSalinhy Barrier FROM TO MATERIAL rUIPLACOMri METHOD
ElAquifer Test 08tormwatar Drainage fL
ft
DExperimental Technology oSubsidence Control ft.
oGeothermal(Closed Loop) OTracer 207DRILLING LOG(attach additional sheets if necessary)
DGeothermal Meating/Cooling Return) 00ther(explain under#21 Remarks) FROA' To RESCM110N(color,hardness,soil/rack in sae,e-)
O ft. ft.
51A
4.Date Well(s)Completed: 7—tS-ZI Well w#AAO- 61S- 3 f, 7/o ft- j,6 le,
Sa.Well Lbeition: Phone # R4-97Y-37170 7l ft- 5-V 3 ft
5,4,W 4'54 t I-Vew ft ft. I
Facility/Owner Name 1, Facility M#(if applicable)
I ft ft.
J r4 X
Physical AAdress,&y,and Zip a ft ft
2L RMqARVS
couity 7: Parcel Identification No.(PIN) 4614o JAV 0 2 S?e_v1 C'J".rr,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
W
6.Is(are)the weU(s):*ermauent or OT orary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: llyeo"' qi 0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction b7forma(Ln 1Z.Atp,lain the nature of the of this record has been provided to7the well ofoner.
repalwAder#21 remarks section or on the back ofthliform.
23.Site diagram or additional well details:
8.For GeoprobrJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is ed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remark Box).You may also attach additional pages if necessary.
drilled: ne 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �4*3 —(ft
For multiple wells list all depths ifdiffereni-(Pxample-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original formto Division of Water Resources (DWR),
lfwater level is above casing,use Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617
, . Bit Off: 24b.For Injection Wells:Copy to!DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in) Program,1636 MSC,Raleigh,NC 2709-1636
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 department of The county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWI;Z,CCPCUA
l Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) Method of test-, 41 Ik, I ,
70%HTH Amount: 117LI 0z DATE SITE VISITED:
13b.Disinfection typeA
VISITED BY: L4,a
e,,vised§-6-2018
Forin GW-1 North Carolina Department ofEnviromnental Quality-Division of Water Resources R
I C E, dWL elm& IV 44.OLL
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