GW1-2022-08834_Well Construction - GW1_20220912

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WELL71VSTIeiJC TiflN REQ ORdD 1GW-11 For Internal Use Only:
1.Well Contractor Information: . �1
�ybe.a+jL U'W)7tK /�/ 14.WATER ZONES
We➢Cm emeNameN /�� TO DMCIION
NCWe➢Cmbactor CertifiAabmNmobw MOITDIACAB[NG Iormdti-raardwdb OALINER der hcable
YADIGN WELL COMPANY,INC, saoM To DusuraR Tfficrr»ss MATRRiAL
R R
Company Name 1 h 3 �gG��- 7°IO.� 16.INNER MG OR TIBIIVG thermal dosed-loo
2.Well Cometructiou Permitk: n 1�•6 30 — 2�22 FROM TO mAaRfEa amnava�.sts MATCUpAL
Lost all applicable well canstrucilun permits(ia fBC,Covey,siale,varimu:,etc) ( It It
6e IR I6 GR •f
3.Well Use(checkwell use): ft I ft is
Water Supply Wall: 17.SCREEN
FROM TO DLVdYCsa Br.Of BII8 THIC aMS I MATERIAL
DAgrimlhual p}./,��IcrpaVPublic tt. ft. In
DGeolhermat(Heating/Cooling Supply) CResidential Water Supply(single) R n. in.
OlRdustriaUCommercial ORrsidet"l Water sopply(shared) 1L GROUT
Dirrigation OWells>100000 GPD FROM I TO I MATERUL I EnITIACIMet1T METHOD®AMOUNT
Non-Water Supply Well: �e,e^, 0 �r� �.Lt
❑M®imcing YJ 60my R ft.
Injection Well: +-- tt.F�� R R
OAgtrifer Recharge 2`d3(iroundwater Remedietien
SSrP 19.SAMGRAVEL PACE der Grable
OAquiferStorageandRedlS (s1,SAIM4yBarrier FROM TO MATERIAL EW1ACBt11RNTMrrHOD
+cr
DAquiter Test .`"' rt��?a"... J ft fL,.;.`.:,-- ,pGOStormweter Drainage
DExperimental Technology '' OSubsidence Contol R R
DGerthermal(Closed Loop) OTracer 20. LOG(attack additional sheets if necessary)
DOeothermal eating/Cooling Reborn) DOtber(explain under Y2l Remadcs) vf
To nasar�aox came.aerdaea,roNmra etc.
n / 3 R So., If
4.Date Well(s)Completed: "1 Well m# AAP—t�3V r o R' S' , s-
5a.WeBLocation: Phone #'Ps,/- 7r'T ff9 ft-
ft
!—s1 F 2sa EnVri a tz fLFuality MO(ffmilir+ble) 04D It t . "al
116
Phycal Address,City.and R R
n REMARKS
Catimy Pena]rdm6firatian Na(rni) qq
5b.Latitude and longitude in degreea/minutes/seconds or decimal degrees: 17 ? O d� goo_zo
(ifwa0 fold.me Iethaagic suffident) 2Z.CertiSea on:
".3ko U. 0-11 N � �K . S-F 7 �1 s2
6.Is(are)the w'ell(s): Mlermanent or OTemporary Sign fCertified Well Cmtnetor Date
Byslgning thbjiorn,T hereby certify that the well(s)was(were)cmunvcted in acrordonce with
7.Is this a repair to an existing well: DYes or 9Ao I5ANGIC 07C.0100 or l5ANCAC 07C.0700 Weti Construction Sondardr and lhaf a ropy
Ifthin it a repair,fill out Moan well constmcdon brformatiun and explain the nature ofthe ofthis record has bem provided to the wall owner.
repair under#21 mmarM seWar or on the back af this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the isme You may use the back of this page to provide additional well construction info
caustrmaion.only I OW-1 is n9bded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also atdch additional pages if necessary.
drilled: �j 24.SUBN TTAL INSTRUCTIONS
9.Total well depth below land surface: —�—`R') Submit this GW-1 within 30 days of well completion per the following:
For m triple walls list all depths if&fferenl(examplo-3 00'and2@100)
10.Static water level below top of casing: 90 (�) Ua• For AR Wells: Original Than to Division of Water Resources (DWR),
Ifwow level Is above casing �• Infmmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (Ito) BR Off.S, 1 y 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
72.Well construction method: AIR ROTARY 24e.For Water Snpp1Y and Oven-Loop Geothermal Return Wells:Copy to the
(La anser.mmry,mbl%wised pock,eta) county enviromocalal health departoient of the county where installed
FOR WATER SUPPLY WELIS ONLY: 24d.For Water Wells oraducing over 100 000 GPD:Copy to DWR,CCPCUA
(gp ) I Method of teat: 91 r Permit grwi,1611 er ,NC 27 9-I 11
13s.Yield m r
13b.Disinfection type: 70%HTH Amount: L OZ DA ITE VISITED:.C—.� —�� fNeV M.,-
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