GW1-2022-08424_Well Construction - GW1_20220408

1-fWELL'CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
iso
/'()Lovkl 14.WATER ZONES
Well Contractor Na I me
FROM
-3og / 410 TO DrSaUYTION
_1 -to__r 4 1
�> 010rr A APR 0 9 2022 ft. it
NC Well Contractor Certification Number 4MTE14 CASING forniulti-ces`ed;wells)ORLINER(ifaPplicable
YADKJN WELL COMPANY,INC. FROM I TO DIAMETER Tffi MATERIAL
Company Name S401�0A 5( "J
� 16.MNF R CASTING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 3 51-9 8' FROM TO Dikharm TEaCIOWS h%'TATEJRMIAT,
List all applicable well construction permits rie.WC,County,State,Variance,etc.) -f / it
I R 't S A' in.
3.Well Use(checkwell use), & — ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SUE THICKNlr-ss MATERIAL
ELAgricultural 13Municipal/Public ft. in.
DGeothernial(Heating/Cooling Supply) Uesidential Water Supply(single) f ;;11 ft,
DIndustrial/Cominercial DResidential Water Supply(shared) 18.GROUT
DIrrigation owells>100,006 GPD FROM TO MATERIAL.I EMPLACEMENT METHOD&AKOUNT
Non-Water Supply Well:
DMonitoring ORerovery fL 7
3
FROM
:10UNT
0
fL
Injection Well: ft %
DAquifer Recharge,. 0 Groundwater Remediation 19
19.SANDIGRAVEL PACK(if appUc2ble)
DAquifer Storage s'nd Recovery OSalinity Barrier FROM TO MATERIAL WVLACMMMNTMETIXOD
DAquifer Test OStormwater Drainage
[]Experimental Technology OSubsidence Control it
OGeothm-mal(Closed Loop) [:]Tracer 20.DRELLUiG LOG(attach additional sheet if necessary)
DGeothermal(Heating/CoolingRetom) 001her(explain under#21 Remarks) FROM TO DESCRIPTION(color,hm-dnesi,wail/rock typc ak stm,et..)
e f. -Vo ft x
L 6"1
4.Date Wells)Completed: 1-2 Z Well
m# cl�t, !V0 ft. yoo So AA SXd
Sa.Well Location- Phone # 973- Pk..WX 00 4'() ft-
6
A10 k In &JnrP'4 ft. ft
FacilitylOwnerName Facility ID#Cif applicable) R %
ft.
Cr
Physical,Address,City,and Zip fL ft.
+a 21.REALUM
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one lattlong is sufficient) 22.Certification:
kO*
6.Is(are)the well(s):43Permanent or OTemporary Signaore of Crrtifre-d Well Contractor Date
By signing thisfarm,]hereby certifythat the wells)was(Wen)constructed accordance with
7.Is this a repair to an existing well: oYes, or OX/I 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction SYandards and that a copy
,phis is a repair pi out known well construction information and explain the nature of the ofthis record has been provided to the well amier.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction filfb
construction,only I GYl is needed. Indicate TOTAL NUMBER of wells (add'See Oyer'in Remarks Bpx).,You may also attach additional pages if necessary.
drilled:— '6* z 24.SUBMITTAL INSTRUCTIONS
o
9.Total well depth below land surface: (ft.) 1 4
-3@200'and2@1001 ZYS
For multiple wells 1W all depths If different(example Submit this GW­1 within 30 d of well completion per the following:
L )WR)
30 24a. For All Wells. Original form to Division of Water Resources (I
10.Static water levtl below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level Is above casing,use
11.Borehole diameter: sit off,-6, 7q 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
AIR ROTARY
12.well construction method' 24c.For Water Supply and Opdri-Loop Geothermal Return Wells:
Copy to the
rotary,
(jr.auger, cable,direct push,etc.) county environmental health department of the county where OR
FOR WATER SUP-PLY WELLS ONLY: 24d.For Water wells producin I g over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: P,iS #,,I f pp
13b.Disinfection type:
70%HTH Amount 3 Ll OZ DATE SITE VISITED:
:
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