GW1-2022-08846_Well Construction - GW1_20220912

' .;i CGJIYSII '1LTCTIT+IDN 1 !CO11 ➢LG -I) For Internal Use Only: j
1.Well Contractor Information:
M WATERZONES. 1
Well Contractor Name Mom - TO DTtaCIt n0N �f
83 ft �prn c�l
at 4 S)A ft IL .
NC well Contractor CertiScatinnNtmber �j
FROM ER CASING for multi-cased�v�S ORLINF1i if a livable
YADKIN WELL COMPANY-INC. FROM To Dulvmm - MUCHNnS MATERML
. - ft• ft. iri. -
Company Name
p 16.RqN R CASING OR TUBING' thermal dosed-loo
2.Well Construction Permit#: _ 3 s3 / FROM To _ D TfficlavEss_ MATERIAL i
List all applicable well constructlan perm�ls(La Mr,County,Slate,Yarlance etc) ft.
3.Well Use(checkwell use): ft R' in. �r
Water Supply Well: 17.SCREEN .
PROM,. TO DIAMETER I,SLOTsIZE Tmcia zs MATERL,L
❑Agricultural ❑MimicipaWublic
❑Geothermal(Heating/Cooling Supply). �tesidential Water Supply(single) % R. ;a
❑Industrial/Commerc'tal ❑Residential Water Supply(shared) IS.GROUT-- -
❑Irrigation OWelis>100,000,GPD FROM _ I.To MATEMAL EMPLACERIMTnmTaOD&AMOUNT
Non-Water Supply Wellh d it- R' Oak f VusvJ S b4
❑Monitoring DReouvery LI ft 01wGK&&A
Injection Well:
ft: !t
❑Aquifer Recharge ❑Groundwater Remediation I9.SAPIDIGRAVEL PACK da livable
❑Aquifer Storage and Recovery OSalmity Hosier FROM TO. MATERIAL MaIA EWNTMEMOD l
❑Aquifer Test OStormwaterDrainage ft fL
❑Experimental Technology ❑Subsidence Control, ft it
❑Geothmmal(ClosedLoop) ❑Tracer 20.DRILLING LOG(attack additionelsheatsifnecessa
❑G m eotheral(Heating/Cooling ROmp) _ 00ther(explain under#21 Renleft). ' EOM TO. DE5CRIP QON color hardaesa,'sol/rocic ate.)
ft. asp'
4.Date Well(s)Completed: "-+ Well ID#A14 0-fG5 5'y 222 ft (,rhn.l f
5a.Well Location: Phone# -:C -231 I ft.
Facrlity/OwnerName FacilityIDtl(ifappliaablb) ft &
2W G- ft I • . , ,_... n r, ,..,.
Physical AAd=r, ,and zip, ft ft r ! Z7
Ve f�L I ai' 2L RFl1 ~
County PmzdIdenti5aationNo.(PII+T) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis'sufficient) 22:Certification.
3 /a .,�, tf.,U N $j .&4 .2 C,VA W t?�23122.
6.Is(are)the well(s): IrPermanent or ❑Temporary Sigaa of Ce Med Well Contractar Date
Byslgningthisfmm,Therebycan ythatthewell(s)was(were),constructed in accordance with
7.Is this a repair to an'existing well: OYes or $No 15A NCAC 02C'.0100 or l3A NCAC 02C.0200 Nell Construction Mandards and that a copy
Ifthis is a repair,fill out!mown we11 construcHpn*motion and erplain the nature of the of this record has been provided to the well owner.
repair underZl remarks section or omthe.back of this form.
23.Site diagram or additional'Well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well construction info
construction,only l GW-.l is needed Indicate TOTALNUIVi13ER of wells (add,See Over'inRemaft Box):•You may also atiach additional pages•if necessm-y,.
drilled: L 24.MMAff1TAL INSTRUCTIONS.
9.Total well depth below land surface: ZZZ�- (ft)
For multiple wells list all depihs If&ffenni(etatnple-3(a 200'and Z(aj100� Suhmit this GW-1 within A days of well completion per the following:
24a:For. All Wells: Original,forth to Division of Water Resources WR
10.Static water level below top of casing:'. - T P . (fL)' Information Processing lIA 1611 MSC,Raleigh,NC 27699-1617 ).
7fwater level is above casing,use"+" I
11.Borehole diameter• 00
6 (in.) Bit Off. a 24b.For Weetion Wells:Copy to DWR,Underground Injection Control COC)
Program,-1636 MSC,Raleigb,14C27699=1636
AIR ROTARY
12.Well construction rnetbod: 24c.For Water'Snpply and Open-Loop Geothermal Return Wells:Copy to the
(Le,auger.rotary,cable,direct push,at;,) county environmental health department of the county where installed �.
FOR WATER SUPPLY-WELLS ONLY. 24d.For Wafer Wells producing•over 100,000 GPD Co to D .4j s Pennit Progiam,1611 MSC,Raleigh,NC 27699-I611 Copy W CCPCUA e
13a.Yield(gpm) "' -- Method of test: ( r.i!
70%HTH �• OZ DATE SITE VISITED: �'- l$-z—)
13b.DWnRction type: ._ Amount:
VISITED BY: .
l�ri r•P• 33+
Fnnn r:W-1 North.Catalina.DeoartrnenGaf;EnviranmentaLOunHty_-..nivicinn.n£Wnter_Rmnnrr. 19�...J