GW1-2022-03139_Well Construction - GW1_20220214

-' RML CONSTRUCTION RECORD(dam'-1) For Internal Use Only:
1.Well Coiitractor Information:
�. `
J d (� �/ ��3 .W ��11 14.WATER ZONES
FROM TO DESCRUTION
Well Contractor N e s Q ft ft' O
aS�1- t tB 1 4 ZRZ 0 ft
NC Well Contractor Certification Number
Uf1M
15.OUTER.CASING(for multi-casedw ORLTNF.R rfa licnblc
YAD19N WELL COMPANY,INC. 1 1i0c�P FROM To DM1[IATER THICKNESs MATERIAL
ft. ft
Company Name S',��lel 3�C� 43 ^�uo 3
_ 16.11qTER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �C�.� FROM To DLkM]'rER TMCIINISS MATERLA.
List all applicable well construction permits rz,e.WC,County,State,Yariance,etc) ! R G J3s in. s D IPVG
3.Well Use(checkwell use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DMAMIrER SLAT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mimicipal/Public ft, g, in.
❑Geothermal(Heating/Cooling Supply) 06sidential Water Supply(single) tt. In,
❑IndustriaVCommercial ❑Residential Water Supply(shared) Is.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EKU ACEKENT METHOD&AMOUNT
Non-Water Supply Well: ft I ft. r'& Ur2�0
❑Monitoring ❑Recovery q ft. D ' it ,SW Or,,%
pow
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK Ra licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL n9l ACEMENTMETROD
❑Aquifer Test ❑St irawater Drainage R ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTNGLOG attach additional sheets if necessary)
❑Geothermal(Heating/Coorml;Re mn) ❑Other(explain under#21 Remarks) FROM To Dascal=ON color,hardnen,zoiYracktypa gmin sae,ctc
q ft ft 4.
4.Date Well(s)Completed:/.�)-22 WeHiD# ` gs ft• ay7"ft & y-e
5a.Well Location: Nw_�� 6 44 fL ft '
Phone # sc;. . .372
Uay Ch,%Jkry 1Sr_
FacilitgiowneraN'amep n Facility lD#(if oppArable) ft. ft
C°Yf*:P+ LJY� kA i'1Ei1 Q190 '� ft. ft
Physical Address,City'
and Zip'
fL ft.
S zl.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesitminutes/seconds or decimal degrees:
(ifwell field,one lit/lbugis sufficient) 22.Certification:
® 17 e T �� N RQ0 l � .
6.Is(are)the well(s): ❑Permanent or ❑Tempora re of Ce ed all Contractor Date
ry S'
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: ❑Yes or 8No I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction information and explain the nature of the of this retard has bear provided to the well owner.
repair render#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
ll.For Geoprobe/DPT or Closed-Loop Geothermal Wells baying the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarlcs Box).You may also attach additional pages if necessary.
drilled: 24.SUBN=AL INSTRUCTIONS
9.Total well depth below land surface: das� (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(eromple-3@200'and 2®100D
' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Intimation Processing Unit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+'
Il.Borehole diameter (th,) Bit Off: �a� 24b.For Infection Wells: Copy to DWR,Underground Injection Control (IUC)Program,1636 MSC,Raleigb,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
S Method of test: %� Permit Pmgrano,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Q^�®
13b.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED:
VIS ITED-BY: uy7