HomeMy WebLinkAboutGW1-2022-09495_Well Construction - GW1_20221014 L CO NSMUC Y111 N KLC®Rd➢{GRr-11 For Internal Use Only:
1.well Contractor'Inffoormation:
14.WATER ZONES
TROM TO DE4LRVt7ON
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NC Well Contractor CutifinetirmNr®ber 15.OUTERC G for mdtiraaed rerIla OALIIrEA d Unbla
FROM D Tla MA
YADION WELL COMPANY,INC. R In.
Comp¢ayName � '!.-� r �S ;�-- 36.1NNEA CASING OR TUBING ittermd rlased-loo
CA44 r1 iA� FROM TO D7AMC1'8R TffiCIQiEa6 MAT6RSAL
2.Well Construction Permit#: R ft r m.
Lin all applicable we0 ronatru4lon porn s(le.UIC.Cowry,SYate,Parlance,ate.) be
R ft. th
3.Well Use(cbeckwell use): d
17.SCREEN s
K
Supply Well: mom To olAaura slm rm 'rmClasss MATERIAL
ultnral oMl!lmiiipal/Public ft. In•
ermal(Heating/Cooling Supply) @Residential Water Supply(single) g, a
triaYCommercied DRcsidential Water Supply(shared) 18.GROUT
� oWells>100,000 GPD FROM To MATERW. HSFf ,axngrrr METHOD•AMOUNT
rt. f 2 R g f GA4 !2
ater Supply Wedl:ilmiug DRecovery R Ron Well: R Rkr Recharge oGroundwater Remcdiation 19.SANDIGSAVEL PACE der linhle
fer Storage and Rec very oSalinity Barrier FROM TD MATERIAL EMPIACDONTMETROD
ifer Test OStormwetwDrama- R Rerimental Technology oSubsidence Control fL
thermal(Closed Loop) DTracer 20.DRII.LING G attach additional sheets ifzis
FROM TO mar7UPTION rotor aaNam.malmrk sbe,etc
DOeotherma)(HeatinglCooling Retom) ❑Other(explain under#21 Remarks) R R
q p rr
4.Date Well(s)Completed: I'ZZ' 2Z- Well w#� O ft' I R
R R
5s.Well Location: Phone #��_e � ���->'
rt R
6w.y �i fi r►+.= �` ' fL R
Fen➢ity/ aNeme F,uIdyID#(rfyrphcable)
R R
o'xi,+ S (city r 9ko'&-% R ft.Physical Address,W`yJ,and Zip 21.REMARKS
;
Corte Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(ifwell field,one lat/long is suHicirnt) 22.Certification:
�..// Si a of Certified Wall Cmtiactu Dole
6.Ie(are)the well(s): L'Rermaoeot or OTemporary
�,� Bys/gnvrgthitfmm,]hereby tert�'draf fhewel!(t)was(Wert.)ronstrucldard andthat a with
7.Is this a repair to an existing well: DYes or rx`u 15ANCAC 02C.0100 or ISA NCAC 07C.0700 Well Construction Stan
and Item o ropy
Iffhu 0 o repair,fell wl known will construction it formation anderplaor the nmme of fhe
jfrhis record has been provided to she well owna.
repairwder 121 mma*section or an the back ojlhis jorm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha*gthe same You may use the beck of this page to additional well construction info
construction,only 1 G 1 is needed. Indicate TOTAL�ER of wells (add'Sw Over'in Remarks Box).You may also etterL additional pages if necessary.
drilled: b , 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �`et (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells Ili all depths ffdiffer a l(example-3Q200'wd3®100`)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information ProcessingU dt,1617 MSC,Raleigh,NC 27699-1617
)jwater lever Is above wring,use"+" (�
Bit Off: �-.1 i o S 74b.For injection-Wells: Copy to DWR,Underground Infection Control (IUC)
11.Borehole diameter: Co (tor) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Suanlv and Oven-Loop Geothermal Return Wells:Copy to the
(Co.auger.rotary,cable,direct pusb,eta) county euviromnentel health deperMent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit gram,1611 MSC,Raleigh,NC 27699-1611 -V v „
13a.Yield(gpm) :114 Method of test: f_ (X air
r
70%HTH 41L OZ DATE SITE VISITED:
13b.Disinfeetion type: Amount:
_ J• e hN1 J.VISITED BY:
c,....,raw_r anh Carolina Depat at nvirmmmtal Quality-Division of Water Resources Revised 6fr201g