GW1-2022-07482_Well Construction - GW1_20220810

S Ji'1 UCTION RECORD�GW-1) For Internal Use Only:
1.Well Contractor Information:
Y ��ecc (�d'�k-c•�
• � 1 14.WATER ZONES !
R.` I FROM I TO TIDESCRIPnON
We11 Contractor Name ` ft,
-NU%-n j04 ft. ft.
Va
NC WeD Contractor Certification Number 15.OUTER CASING for niniti cased vrrlls OR LINER(if a lirabk
YAUION WELL COMPANY,INC. FROM To nuMicTVR TfficaatFss MATERiAI.
fL fL in. _�
;CompamyName 16.rNNER CASING OR TUBING eothermal dosed loo
Construction Permit#: FROM TO DIAM M%R THICKNESS MATE87AL
Lial all applicable well construction pwalirs(ae UIC County,State,Fariance etc) fL y y & to/ in.
saga 1 ,f
3.Well Use(check well use): ft ft• m•
Water Supply Well: 17.SCREEN
' FROM TO DIAMETER SLUT SIZE TMCIGaSS MATERIAL
OAgricultural ❑MunicipaUPublic
j ❑CWthenrlal(Heating/COoling Supply) ptesidential Water Supply(single) g ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
l M3igat10A ❑Wells>100,000GPD FROM I TO MATERML EMPLACEMENT METHOD&AMOUNT
j Notl:Water Supply Well: ft, 3 ft. (�k!P POorej
4 ❑Monitoring ❑Recovery 3 ft ?2 ft. ©v
Injection Well: ft• ft.
f ❑tlgliiferRecharge ❑Groundwa=Remediation
19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control fL ft.
Geothermal(Closed Loop) ❑Tracer 10.DRILLING LOG attach additional sheets if necessary)
r FROM TO DESCRIPTION cator,hardness,xoWmcktypc,van s'ne,etc
0Geothermal(Heating/CoolingRetum() ❑Other(explain under#21 Remarla) fL 3$ fL O ./
4.Date FVeU�(s)'Completed: 8 �'` Well ID# C 1 3g ft
fL 00 ft
Sa.Well Location: Phone # ,35G-2q! . `/ 3fl
n f� f. fL
-5r ft
Facility/OwneerrName Facility tM#Cif applicable) ft. AUG
&D �r✓G� �f�y t� F'���' fL fL
Physical Address.City.and Zap o�lL fL ft. 50nrC CdB��lS� sea
zx.RElvrAaxs my MOG
Cotmty �'! Parcel Identification No.(FIN) ® J
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(iffweeD field,once lat/longis sufficient) 22.Certification:
W 8A)CaA
a,Z
6.Is(are)the well(s): jPermanent or ❑Temporary 4Sigarf1 ad 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: ❑Yes or ,�l I0 15A NCAC 02C.0100 or 15A NCAC 62C.0100 Well Construction Standards and that a ropy
If this is a repair,fill out known well construction information and explain the nature of the afihls record has been provided to the well owner
repair under f2I remarks section or on the back of this 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 Remariz Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &obi (ft') Submit this GW-1 within 30 days of well completion per the following: s
For multiple wells list all depths if d(�erent(example-3@200'and 1®1001
�� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR), ;=C1
10.Static water level below top of casing: Information Processing Unit,161:7 MSC,Raleigh,NC 27699-1617 l:
if water level is above casing,use
Bit Off: 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) F
11.Borehole diameter: (�) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:_Copy to the
(ie.auger,rotary,cable,direct pusb,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
e Permit Program,1611 MSC,Ralf igh,NC 27699-1611
13a.Yield(gpm) � Method of test: Ql�
70°/ HTH OZ DATE SITE V151TED: i 7` 2'
13b.Disinfecfion type: ° Amount: ; _ 3/+A
Uri rP•
�.� VISITED BY: 1, J�
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n-18.,- ,.f Revised 6-6-2a18