GW1-2022-07579_Well Construction - GW1_20220815

+CofitlTiJC1TlZOIe1 (da�V+ -1) For Internal Use`Only �
I.Weil Contract&Information:
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14aWATEXZONES
Well ConhactorName $ rrROMw I.TO VDBSCRIPTlON
y,/`•,I, P-\ /'� ��93�a �`{t��; wm? � r• - rg,:
NC Well Contractor Certification Ntmibc n
' QIJr J v 202Z 1s OUTER CASING form�lh"�sed,wellsrUIirLINER`�fa liratilb
YADIoN WELL COMPANY,)NO.
raoM :. NTo ya,: sDrlMsrmz: a.TfficraVEs51�B iMATBRIAL
Company Name 0 16 s rc. � x r
ViJ ae, INNER CASIlVG OB'rTUBING" eoth ermal Cdosetl=•loo
2.Well COnBtrUCt10R Permit#:_ �� � V� UM d +tTO u'. 11MMrM t4TmcramS1r/MATEBLIZ •
g�+n• r.,
List all applicable well construction peIM
rmits a Ma County,Stole,Yar!ance,etcJ tsD�n p /' M
3.Well Use(check well use):
Water Supply Well: lI7?SCREEN
x MOM am*TO SSI.oLSMEN)<THICiQYESS)r 1MATERlALi
❑Agricultural ❑MunicipaUPubLnya ,„,�� � ft`.• ft. in.
❑Geothermal(Fieahng/Cooling Supply) `,-Xesidential Water Supply(srrigle)
❑IndushiaUCommercial ❑Residential WeterSupP1Y(sha ) IBIGROUT
❑Irrigation Dwells>100,000'GPD "• c>; 3 C FrioM IIMATMUAL ifEMPi rcanrEr�T,MaTHOD'ar,�►tOmfr�
Non-Water Supply Well: ftvat
❑Monitoring ❑Recovery;- r Ott Y it dr R r r� `L
Injection Well: , • [• t �Tt r r u
ft: ft C
❑Aquifer Recharge ❑Groundwer`Remetiiations191SAP1))IGRtiVEL~PACK ff runU�bl'e
❑Aquifer Storage and Recovery l7$abnity,l3emer l�!tti�Ront lsTo 1M�rERrti1 �En�lacEeusert;Max$oDtltrllilr
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology, ❑Subside#$,Cool � ft it
ni-
❑Geothermal(Closed Loop) OTraeersDRII;ITIVGLOG'a'Nach?addffiWw2ssheets�a
. I�FBOM o. ?D&SCRIPTlONi ealaa-p—as^"Ts eoi7lmcli❑Geothermal(Fieating/CoolingRetom) ❑Other(explainunder#211Remedss)
Q T3ateFVeI1(s)Completed: �3 Weu1D# �'J;C: 3�.iv �'r�G�f,
s
5a:wellI,ocation Phone# �' 8 —�� 'r2a �I �Q , �
Via, .
Facility/Owner Name FacrldyID# if an
�""-aelile •
r, cal
ZVeZa
sisal Address,city and Zip �U
Couaty s {' Parcel IIileni oatmn No..,(PT1I) � 1f1`
5b.Latitude and longitude La degrees/minutes/seconds or decimal degrees t •
(ifwell ECK One lat/longis suffieieat) " fi "-
, � i�22 Certification:
' Conhactor bete 6.Is(are):the well(s): �kerpianent or •' ❑Temporary 41
r �Srgaatnie—Of Gertified Will
i3yslgnngthisform Iherebycerijfyihalflieweff(aJwaa.(ware)cons0ycted-inaamrdmicew 7
7.Is this a repair to an existing well: ❑Yes orD 113A NCAC•02C0I000or�%SA�NCi1C 02C.0200 Wefl Construdlon SYandards.and that a copy i
If this is a repair,fill out known well construction k1formation d ezplmn'the nature of the of this record has been providedto:the well miner i
repair vnder#21 remarks section or an the back of this form.
;� :Z3 Srte diagram or additionalweu details:
i o m
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the s
GW1 amei:�t add'See Over,
m bRemarks.H PYO m alsoeattech addihonal, �construction,only 1 ' needed.Indicate:TOTAL NUMBER of wells • ) aY pages>f necessary.
dn7led � .
�A �Af�24`SUBNIITTAL INSTRUL'IT( NS
9.Total well depth below land surface:
For multiple wells list all depths,lfdifferent(wxample-3(a)200 and 2®10 ) a Submit this GW-1 withinr30'days+of well completion per the.following: 1
� � � :lG)
�1st a For Al! Wells. Origial n form to Division of Water Rrsources (DWRj,
10.Static water level below.top of casing: '20 x+ u (f Infoimati n Pmcessin U ' 17
-if wate4level is above casing,use"+" � j ;r J g ' MSC Raleigh,NC2T699-16I7'
11.Borehole diameter: ( ,} Bit Qff s i 7s)b For.Intection Wells: Dopy to DWR,Underground Injection Control(IU�
Pm10am,1636 MSC Raleigh,NC 27699-1636
f 12.Well construction method: AIR ROTARY ,., �24c For'Water S oply and,Up T.o�op;,GeothermaLReturn Wells:Copy to tha
1• (ie.auge{rotary,cable,direct pusli,etc.)
county eftyntnmental health`departaient of the'county whr installed i
FOR WATER SUPPLXeWy9TYS ONLY: all,y4d uForWar Nod MUM. py to D WR,CCdP GUA
PiogTaro;=161,T MSCMRaleigh�NC 27699=16U1
13a.Yield(gpm) Method of test:
70%HTHt rUN
'DATE SITE VISITED:
,,a 13b.Disinfection type: Amount: r �� C