GW1-2022-08917_Well Construction - GW1_20220912

WELL ICONS Ill '1fJCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J CCC`'1 Wc.�J�CfAS 14.wATER20NlE3 i
-f FR011f TO DESCRIPTION
ft I Well Contractor Name
4!D A ft It
NC Well Contractor Certification Number
15.0UTERCASING foruiulti-cased wells ORLINlER ifa livable
YADIdN WELL COMPANY,INC. FROM TO DIAMETER THICIQVESS MATERIAL
Company Name
/y p 16.INNER CASING OR TUBING eothermal rlosedaoo
2.Well Construction Permit#:— (n!/ /J 3 FROM TO DIAMETER I THICENESS nATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc) .� Eft (j sle t f 198 v,
3.Well Use(checkwell use): ft ft• m. t
Water Supply Well: 17.5CREEN (\�
FROM TO DLAMETERi SLOT SIZE THICICNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) #esidential Water Supply(single)
ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
OIlrigation 100,000 GPD FROM TO MATERAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W :„ : 4 vv 5 ft. q ft. 1401YAl
❑Monitoring very y it '�/ ft Owtk ds^Ou( •dR` 2� Y2
Injection Well: F
ft❑Aquifer Recharge ft.
tleti �lr Remediation
1 t fi` 19.SAND/GRAVEL PACKrifaDDUmble)
❑Aquifer Storage and UWW1 Barrier FROM TO I MATERIAL I EMPLACE117EN f?ETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRII LING LOG attach additional sheets if necessary)
❑Geothermal(HeatinglCocling Retmn) ❑Other(explain under#21 Remm1m) FsoMI TOO' DESCRIPTION color,hardness,soiVroorr ,G .. size,eta
Q J v tt J S ft o t
a.Date Well(s)Completed: gill 7 Well ID# ,P G -3 ss R' /0031 `Q k
5a.Well Location: Phone # fo ft ft
ft fL
Fae dvm Ne-e Facility ID#Cif applicable) ft. ft
I / f%y e r o e-ou. 7;i titJ.Gl G1X;V ft ft
Physical Add-;..City,and Zip ft ft.
�j 21.REMARKS
-A f P�
County Panel Identification No.a1N)
5b.Latitude and long-itude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
b.Is(are)the well(s): ermanent or ❑Temporary Signafare of ertified Well Contractor Date
(( By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 00 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fdl out brown well construction Information End explain the nature of the of this record has been pro vide d to the Nell owner.
repair wider#21 remarkr 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 construction 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: ( 24.SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: {00 (ft)
For multiple wells list all depths(different(example-3@200'and2(a}100D Submit this GW-1 within 30 days of well completion per the following:
( 5O ) 24a. For All Wells: Original fb6 to Division of Water Resources (DWR),
Ifwoter level is above casing,use
f Static water level below tap of casing: (ft Information Processing Ua t,1617 MSC,Raleigh,NC 27699-1617
"+' �
11.Borehole diameter: (in.) Bit Off: to•0 WI 24b•For Injection Wells;Copy to DWR,Underground Injection Control.(IUC)
Program,1636 MSC,Raleigb,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the -y
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed L
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPC A-
13a.Yield•(gpm) 1/z- Method of test: .4* Permit Program,1611 MSC,Raleigh,NC 27699-1611 t L �
70%HTH 3 7 OZ DATE SITE VISITED:
13b.Disinfection type: Amount: t �y
P „i cP, �� V151TED'BY: