GW1--04329_Well Construction - GW1_20240722

For Internal Use Only:
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1.Well'Contractor Inf
14.WATER ZONES
111 lll��i(((LLL` FROM TO DFSC
Well Cc.icractor Name ft,
i
ft. I
NC'7.'eil Contractor Certification Number 15.OUTER CASING(for multi-used well1e
YADK.IN WELL COMPANY,INC. FROM 7o A THICIOVEss MATE
RUL
in.
Comp2-n Name Q Vu+4n- /
ki 2 y- t g 16.INNER CASING OR TUBING( eolhermnl dos
We I!Consu ucton Permit#:.S I It I 3 -7 FROM TO DIANfCIER CIOVFS6 AUTERLAL
ft. ft. in.
List.2, zpphcoble well construction permiu(i.e.UIC,County,State,Variance,etc)
k. in.
3 Well Use(check A°ell use):
17.SCREEN
Watel Supply Well: FROM�JT DUM> rER SLOT s r ATER1AL
❑Agr ultural ❑Municipal/Public ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Ind,,,cxia1/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lr�ri-anon ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEM T hTCT90 6 AMOUNT
NI on WzterSupplyWell: ft. � ft.
CMoritocing ❑Recovery ft. fr.
injection Well: ft. ft. I.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAN------ EL PACK(if a liable
I ❑Ap°_:.fcr Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL GA�ffLACEMENTMETHOD
❑AmiUcr Test ❑Stormwater Drainage ft. ft.
I
I❑E,c,erimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 1 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,30ilfrl)cktypt,gniio sac,ctc.
❑G--thermal(Heating/Cooling Retum) ❑Other(explain under 1Y21 Remarks) k ft.
, 1
4.Date Well(s)Completed: Well ID# - (U ft. f, �qm'
V WUV re,&% •x`-7 ft. ft. ,.
5c. •hell Location: Phone # of i c1 - 612- 004'7 '
ft. ft i Lz�..r.._;,1 ,
:urajK r " Le r. —,
F­a;L',,/ONvnerName J / nFalclityID#((if�applieable) ft. ft 1� 2 2 202¢
LAO ' �.J SU—S I t - a.. aI k q " ft. k. 1
s �1Lh
N ft. ft. UP-t
Phys;ce Adicss,City,and Zip e f G:!'iw.l.T r� rrM,',.4
•,. 21.REMARKS
BORES (C) DEPTH #U-) t- � �ti C
Cour•y Panel Identification No.(PIN) l
5b.-,.,atitudr.and longitude in degrees/minutes/seconds or decimal degrees: � LOOPS PER BORE ( / ) DIA OF LOOPS (Ai
(irH•'0 field,one latllongis sufficien() 22.Certification: SDR OF LOOPS
6.1, are) the well(s): ❑Pertnaneot or ❑Temporary Signature of Certified Well Contractor Date
Bysigning thisform,]hereby certify that the well(r)was(were)constructed in accordance with
7.h this a repair to an existing well: ❑Yes or (nNo 15A NCAC 02C.0)00 or 15A HCAC 02C.0200 Well Construction Standards and that a copy
f{ .. is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repo;-under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
R.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
:m,'Tuction,of 1 GW isj'�eded. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
CT;, : - Cr, 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �100 (ft.) Submit this GW-1 within 30 days of well completion Der the following:
For,-ultiple wells list all depths ifd fferent(example-3ta 200'and 2©/00D
y 242. For All Wells: Original form to Division of Water Resources (DWR),
10.':.tatic water level below top of casing: / (ft') Information Processing Unit,1617 MSC,Raleigh,N'17699-1617
lfwr er level is above casing,use
Bit Off:30 0 O 24b.For Injection Wells: Copy to DWR,Underground injection Control (IUC)
11.''orchn:e diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
'12.-NCH construction dlethod' AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(t.c.:uger,rn an•,cable,direct push,etc.) county environmental health department of the county where installed
FO'1 WATER SUPPLY ELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
[I32b.
Yield(gpm) Method of test: ) l)r�urSet t, �'J'2 V
Disinfection type: 70% HTH Amount: OZ DATE SITE VISITED:
PS:L,P , VISITED BY: PJ21. —
Fer-.GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018