GW1-2022-08482_Well Construction - GW1_20220411

�� � .363.'�w'n�.,.z"a'Y+�1 t .7•,x"*',s z 4 t� .�v-�'�b, 'z , _
n
x; x a r sr.-n a ic$� '� k.- <ta > n tt r •.d .... ..t'' •'' Mks '' m
,
t c
FROM PTO !FD&SCRIYdTION :i.'""..
+�s a -
�l95 Sa So D v _ -1 �!01
NC iWeII Contractor CertifieationNnmber 151KUUTEWCASINIGi r—,xdul64Mediivell`s 10RMV.=!if'lieatil`e
`lADK1N 1NELl COMPANY,INC, ytFROMTa fEnIAn�I�Ita
TXr�CraysssMATBRIAL.
Company Name ' `.
W"II4NER1CAS1Ii1GiO ""`4isenrmal closed-loop) � �V �,.
2. Nell Cllnstruction Permit#: *PROMAINN litTTo MDIAMBTER TMCF04ESs I MATERW.
List all,pppllaable,well coastructtan usr C Cow' Slatq`*Yarlan'Mr x
}..:..
_.
3.Well Use(checkwell use): A.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAM TrR SLOT SIZE THICIGitSS MATERIAL
❑Agricultural ❑Mimicipal/Public ft. fr. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it in.
❑Industrial/Commercial (❑_Residential Water Supply(shared) 18 GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTTSETHOD&AMOIINT
Nan-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft ft.
Injection Well: v
ft. ffi
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK da lieable) !�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI ACEMENTMETHOD
❑Aquifer Test ❑Storinwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necrssa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM To DESCR=ON(=]or,hardness,soll/mck a grain she,ete
Q 3`1 2 ft- -7CP2-yL
4.Date Wells)Completed: y�-Z— Well W# p—! 3 & ft'
5a.Well Location: / ,q�Phone # ?D .S3 • ft. fft ft
Facility/OwnerNern Facility ID#(ifapplicable) ft. ft
l Y, lip eo &b 6ct(e, 11y'Lf ft. ft
Physical Address,City,and Zip sL 020 ft ft
-ir'f /1e 21.RE
MAFM
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
,3 g 2 T S-3 N !2 49- 11.l W
6.Is(are)the well(s): Aermanent or ❑Temporary Si#Kre of CediEcdWell Contractor Date
By signing thisform,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an eldsting well: t,'.J�I��es or PINo �� 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out known well construction biformation and ex to fhe n ture of the of this record has been provided to the well owner
repair under i<21 remarks section of an 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 1 C}W-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarics Box).You may also attach additional pages if necessary.
drilled:_ ( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70�' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths lfdi�erent(example-3(a 200'and 2Q100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of easing: (ft.) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
Tfwater level is above casing,use"+" �
Bit Off: ,, 919 24b.For Injection Wells: Copy to DWF-,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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
(i.e.auger,rotary,cable,direct push,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
� Perini
161 �,Raleigh,IQC 27,�99-I611
13a.Yield(gpm) 7 Method of test: �l�t� qq 'Rol e/ t 2 JIB'
70%HTH OZ SITE VISIT
13b.Disinfection type: Amount: