GW1-2022-03510_Well Construction - GW1_20220316

E CONSTRUC1TI+[9N RECORD LGH-D For Internal Use Only:
I.Well Contractor Information: i
4UA 0/1 L 60a✓`i 14.WATER ZONES
Well Con cturName FROM TO DESCRIPTION
��� � G it. r®ft. fG�� o r .c � tat*
ft. ft
NC Well Contractor Cer ificadonNumber 15.OUTER CASING for multi-cased wells ORLINF.R if a livable
YADMN WELL COMPANY,INC. FROM To DIAMETER THICaatEss MATERIAL
ft ft. in.
Company Name �? t " Q 16.INNER CASING OR TUBING eothermal rlosed loo
2.Well Construction Permit#: 3 6 cr FROM I To DiAME R -—F W O s MATERUL
List all applicable well construction pavnfts(i a'UIC,County,State,Variance,etc) R in. J i LE
3.Well Use(checkwell use): ft R' in.
77
Water Supply Well: 17.SCREEN
FROM TO DIAMSfER SLOT SIZE THICIMss MATERIAL A
❑Agricultural ❑MunicipalNublic ft. ft. iv. vl
❑Geothermal(Heating/CoDling Supply) "residential Water Supply(single) ft. it. in.
❑InduStrial/Conun=ial• ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD : . FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT I n
Non-Water Supply Well: ft. 5 ft. l7a^'� e O re&t �f
❑Monitoring ❑Recovery S •it ft.
Inieciioo Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GP.AVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Ban-ier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage R R• h
❑$xperimental Technology ❑Subsidence Control ft ft
❑Geothermal.(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necasa
❑Geotheimal CHea6ig(Cooling Ratan) ❑Other(explain under#21 Remarks) re,
TO DESCRIMON cola,hardness,soillreek che,etc
ft SG•►of S ^ti SA1z14.Date Wel)(s)Compleied: _,1 ;2. WllD# (O .SK ft5a.Well Location �✓ ' 13 a� !''1 t� �dt tat,)i,Phone#3.36tl3®1= ��
h
F ty/Owner Name Facility ID#[3f applicable) 0 L1 fl L1 2
4�-ft- oa.ft
PhysiriaAddress,City and ft ft "._... s`"
!Al,�
^s' 4j O�c� 21.REMARI{.S -
Ca�ty Parcel Identification No.PM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(ifwellfield,one.lst/longiS sufficient) 22.Certification: • h") ` s' �' ;` d
® ram N cSlt� C?Q. C
6.Is(are)the well(s): &?Permanent or ❑Temporary Signature of Certified Well Contractor Date / a
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 10 o 15ANCAC 02C.0100 or 15ANCAC 02C.07001Pe11 Construction&mdords and chat a copy-
lf this is a repair,fili out Imown well construction informatlon and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of ibis form.
• 23.Site diagram or additional well details:
8.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'
construction,only I GW=1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach atitiffional pages if necessary:
drilled: �.'. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft) f I
For multiple wells list all depths lfd"crent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion perrthe folIotving ..
10.Static water level below top of casing: 10 V l (fL) 24a• For All Wells: Original form to Division of Water Resources (DWR),
I10.St level is above casing, w op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Il.Borehole diameter (in.) Bit Offs e "`� 246•For Injection Wells: Copy to'DWR,Underground Injection Control(IOC)
Program,1636 MSC,Raleigh,NCt27699-1636
12.Well construction method: AIR ROTARY I i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie,auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed', 6
FOR WATER SUPPLY WELLS ONLY: 244,For.Water Wells producing)over 100,000 GPD:Copy to DWI?,CCPCUA
l ! Permlt Frogram,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test, su
su
f.
13b.Disinfection type: 70%HTH Amount r OZ DATE SITE dISITEb:�✓9 a 2[-2(
S f1 bISITED BYs. . 4