GW1-2022-08453_Well Construction - GW1_20220513

I
MWLLACONS RUCTION RECORD (GNV-1) For Internal Use Only: i
1.Well Contractor Informntion:
14.WATER 2ANIIS f j
Well Contractor Name FROM TO DFSCRVnON
ft.
3036A > H ft.
NC Well Contractor Certification Number 5J, ft. 7 It IT
15.OUTER CASING for multi-rased*CDs RLRN ilap licable
DIAMETER sYADKN WELL COMPANY,INC. FROM
Mn
Company Name
3- 2�y O 16.DNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 G 3 R FROM To I IN&METER I TMCraMS I MATERrer.
List all applicable well construction permits fl e.UIC,County,State,Variance,etc) ft ft 0 t/yi in. eve,
3.Well Use(check well use): ft fr 1II
Water Supply Well: 17.SCREEN
FROM TO niAMETER SLOT SIZE THIC[CMS5 I MATERIAL
❑Agricultural ❑ icipal/Public ft.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
01rri 'on ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METffOD&AMOUNT
Non-Water Supply Well: ft. ft. A4 G 7
❑Monitoring ❑Recovery 3 ft 2 ft 0 Y
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK da livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO _.MATERIAL, EMPLAC:EMNTMEMOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control it
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necevsd
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM O DESCRD?1TON color.hordaess,roiVmr3c .'a roe ett
ft. ft
4.Date Well(s)Completed:J _Z Z Well ID#A&'-71_a_ 9 -ft fL ft
5a.Well Location: Phone# 3ic-.S z 9- NZg
I
rim r y 1 A_Cb 1n f. ft ft
Facility/Owner Name Facility ID#(rfapplicable) ft- ft
ft- fL
,�ii D ttO
Physical Address,City.and Zip fL R
21.REMARKS
County (� Parcel Identification No.(PLAT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Wang is sufficient) 22.Certification:
6.Is(are)the weli(s): Uf ermanent or ❑Temporary 'Signature of Certified Well Contractor. Date
1.
f / By signing thisfarm,1hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or-- MAO 15A NCAC 02C.0100 or ISANCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,ftll out known well construction information and erplain the nature of the of this record has been provided to the well owner.
repair under#21 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 contraction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: l f 24.SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and
2@1001 Submit this GW-1 within 30 dayis of well completion per the following:
10.Static water level below top of casing: 76) (ft) 24a. For All wells: Original farm to Division of Water Resources (DWR),
lfwater level is above casing,use"+" Information Processing Unit 1617LMSC,Raleigh,NC 27699-1617
Borehole diameter: (in.) Bit Off: 0'f 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,N627699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger,rotary,cable,direct push,etc.) county environmental health depart aient of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin I over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) cQd Method of test: (►/i Permit Program,1611 MSC,Raleigh;NC 27699-1611 6.H
e Cg.1/ M 3 f � .4�"r
dt\ 70%HTH OZ DATE SITE VISITED: z_ix 2 Z @R
.Disinfection type: Amount: Cl - �� W A/1 pev
/Y D1Tb.DiPnf _ ----_ _ -- VISITED BY: tx-m t�e� /I