GW1-2022-03512_Well Construction - GW1_20220316

i
:-'WELL CONS TION RECORD(GW-11) For Internal Use Only:
1.Well C tractot•lnformntion:
( I jJ4✓'� 14.WATER PANES
Well Contractor Name FRO-Al I TO I DESCRIPTION c
� � �•ft. C{ �. ��-. ,. L.-� r d tic ' S 9
ft. _ 01t.'
NC Well Contractor Cmtificahon Number I5.OUTERCASIN formnlfi-rased�v ORLINER tf a cable
YADIaN WELL COMPANY,INC. FROM To 71IAMETEIt MUCENMS MATERIAL
ft ft. ! in.
Company Name �� 16.114NER CASING OR TUBING(geothermal closed loo
2.Well Construction Perm I ��� I FROM To DIAMETa r�c[avEss nv+T>;xuL
List all applicable well construction permits(tie to , ounty,Stare Variance etc) ft- !l in. �,✓` '� r
ft. ft. in.
3.Well Use(checkwell,use):
Supply Well: 17.SCREEN
Water Su pp FROM TO DIAMETER SLOT SIZE ITHICKNESS MATERIAL
OAgricultural OMunicipal/Public
❑Geothermal(Heating/Cooling Supply) Iesidential Water Supply(single) ft. ft. in.
OIndustrial/Commercial OResidential Water Supply(shared) lti.GROUT
❑I,m atiop OWells>'100,000 GPD FROM TO .MATERIAL EMPLACEMENT METHOD&aMOIINT
Non Water Supply Well: q l 1, ft. 14ft. n 'L o' C Y. d�
❑Monitoring ? d. ov it ft: dil 0, r f ,/L. t
Injection We1L• ��pp ii ((�� ''jjQ2',�� ft
OAqugFr Lecharge Mt�f3rt�n3weter -mediation 19.S PACK(dapplicable.) r
❑AquifEr Storage and RCCavery ❑S FROM TO MATEurer• EMPLACEII�+NTMETHOD
OAquifrs Test r �1 ft. S.
OExperimental Technology ` L" ubsidence Control -. ft it
OGeothermal.(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if neerssn
FROM. TO DESCRIPTION color,hardness,wailknrktypr,grain size,at
O(3eothermal(Heafmg/Cooling Return) OOthex(e#lain under#21 Remadcs). -
® ft. ft. S * r
4.Date Well(s)Completed: �� Well b4kml R �r
R
5a.W6llL6cation: Phone #n33�P�S'� -'�38� 'd
v 1 r i 5i 1��1,'Sd�.1�� li7o ,a4 ho wH ®`a�"tt
. ft z,'��
Facility/OwuerNeme FacmyID 0fapplicalile) R ft �1�1 �t G;�G� ��e>p G
Vie{ ft an
. , ''a� tsrb ° f't., ri:•��
P ysivia Address,CdY,and lip z n AJ a%un� f 7
21.REMARKS f
bz6 j :,
County Parcel Identification No.(FIN) A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilongis sufficient) 22;Certification: Y
6.Ls(are)the well ermanent or ❑Temporary
Signature of Certified Well Contator - Date
By signing ihisfmiri,I hereby cert(fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an Blasting well: OYes or Io ISANCAC 02C:01 DO or ISA NCAC 02C.02D0 Well Construction Standards and That o copy
this record has been rovided to the well owner. 1
If this is a repa/r,fdl out known well canshvction information and explain the nature of the of p
i repairsmder#2I remarks section or on the back of this form. r
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" '
(add'See Over'in Remati6 Box).You may also attach additional pages ifnecessary ;
constriction,only 1 GW is needed. Indicate TOTAL NUMBER of wells
dnllerl; /pp 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land-surface: r (ft') Submit this GW-1 within 30 days of well completion:per the following:
For multiple wells list all depths!f different(example-3@200 and 2©100)
( (ft.) 24a. For All Wells: Original form to Divisitm of Water Resources (DWR),
10.Static water level below top of casing: too
: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwaier level is above Casing,use 11,
( ) Bit Off: 6"I 0)��) 24b.For Injection WAl1s: Copy4 to DWR;Underground Injection Control(IUC)
11,Borehole diameter: Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY ):,.d `
12.Well construction method: 24c.For Water Supply and Open Loop Geothermal Return.Welis:Copy to the
cable,direct usb,etc.
(Le auger,rotary, p ) county environmental health department of the county where installed
r L
FOR WATER SUPPLXTVELLS ONLY: 24d;For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611 �`P 3A` ,
13a.Xield(gpm) Method of test tJ:}f/' �► [v' f
` 70%HTH OZ' l7ATE SITE VISITED ���' z .•1'�"��lD
I'13b.Disinfection type: Amount 1= -- A eL Ali 6