GW1-2022-08844_Well Construction - GW1_20220912

`VEEL CONSTRUCT—ION ON RRF"COR f GW-il For Internal Use Only:
1.well Contractor information:
t!e"� TA)NR9
dO30Tv 7 FROM inuard I ro I as9mtanrm IbUTMAL
3 — / 1NC well Contactor Certification Number I&OUTER CA�IG for multi-cased was ORLINER. itu YADION WELL COMPANY,INC. FROM TO sus rm 't CMarssft ft inCompanyName / r', / 16.Rein CASING OR TUBING eotbermal dosed-loo
2.Well Construction Permlt#: O 7 6 -7 !N FROM To auMarim '1'fficfavase MnTrnLin ali applicable well constructionpenrusin C County,State,Ya ca,cats) R R GrfaS in. ..�' v3.Wall Use(check well use): %Water Su Well: 17.S[�PPIY FROM TO D1Aatirm SUnS/7.F. TMOUIESS
ElAgricultmal OMlmicipal/Public D. R. in,
OGeathermel(Heating/Cooling Supply) 11 sidential Water Supply(ringle) ft. ft. in.
EIndusxial/Commercial ![]_Residential Water Supply(shared) IL GROUT
olirrigation OWells>100i,000 CiPD FROM I TO MATSnrAL EMPLACEMR7T METHOD@AMOUNT'
Non-Water Supply Well: ft N- ryfpe, C l
0monitormg oRecovery R R
Injection Well: ft R
OAAquifer Recharge OQroundwe4r Remcdiation
19.SAND/GRAVEL PACK ifa linable
OAquifer Storage and Recuvcry OSatinity Barrier mom To MATSMAL I Dieu MerlloD
a4quifrr Test ❑Stmmwater Drainage R It
oRgerimental Technology OSubsidence Control tL I R
cGeothermal(Closed Loop) OTtacer 20.Tmwx.TNGLOG(atiaeh additional shah ifn
ecessa
OQcmhermel eabiWCooling Retmm) OOthu( lain under#21 Rema3a saou TO msCnBnoN rntarm wv.vdc ate.
ylf
Q���l�y�. �/ D ft R Oi d- �f�{
4.Date Wells)Completed:OL2490o .ID# D � �` R R �iw4 .'A Gast 1 1
5a.Well-Lo/cation: Phone # 33G'� - f` �' R �1 It ''
k91C1 Q red Atiit°y i�r u�r, l7oa twu R R jt
Famlity/Ow�neerrName �N.f(�/4^ �PamlltY C RPti R R
/7 t- l t'S R R
Physical Address.may,and 4 R f t 1
�i�/ e f 21.uxMSRES
city /j Pamtlld, cationNu.(PIN) 7`
5b.Latitude and longitude in degreeshninutes/aeconds or decimal degrees: 1
Clfwan fu1d,one laviongis suffideat) 22.Certificati C
3/ 06 f l/52 N ffO 31 2z 73
6.Is(are)the well(s): ermanent or OTemporary Certified Well Cootacmr Date
slgningthisform,Iha bymrtlfythatthe we11(y)was(were)comrtuctedin a=aMoons with
7.Is this a repair to an existing well: DYes or To 15A NCAC 07C.0100 or/SANCAC 02C.0100 Well Cmstructimi Stm,dards and that a ropy
llthh tr a repair,fall out lnown well consimcffm biformation d espioat the nature of the of this recordhas been provided a the wall owner.
repair undo f2l remorla section or on the back of thlaform. 23.Site diagram or additional well details:
g.For Croprobc/DPT or Closed-Loop Geothermal Wells having the same You may,use the back of This page to provide additional well construction into
construction,only I l3W-1 needed. Indicate TOTAL NUMSRR of wells (add'See Over'in Remsla Box).You may also attach additional pages if necessary.
drillcd: X IT.SUBMITTAL INSTRUCTIONS o
9.Total well depth below land surface: 0 (fL) Submit this GW-1 within 30 days of well completion per the following:
For mu/Opla weAr fig all depths trdosmw(emmpla-3Caj100'and 2®1001
24a. For All Wells: Original than to Division of Water Resources (DWR),
10.Static water level below cap of casing: D (ft.) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617 C
lfwater level is above cntbng,use"+"
11.Borehole it (lu.) Bit Off: �'d 24b.For Eniection Wells:Copy to DWI?,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636 J
12.Well construction method: AIRROTARY Z4c.For Water Supply and Oaen-Loop Geothermal Return Wells:Copy to the
(is,toga,many,eabls.d red push,dG.) county environmental health department of the countywhere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodudn aver 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) / V Method of teat.
✓ PemutPmgmm,l 11 MS Ralci ,N 27699-161
3-tea L
73b.Disinfection type: 70%HTH Amount: /2 OZ DATE SITE VISITED:
Uri ce a VISITED BY:, 4p