GW1-2022-09548_Well Construction - GW1_20221014

:Y&it, it S iJI:t'fi)mCtF'°r= orintemal Use Only:
i•.Kel!Cnot"ttor ir.orma0or,: —
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NC Well Coalractar Certification Numbs 15.OUT'EIt CASING far mvla-usedwelis TMLINEH da Goble
PROM Tra DUMSrBR TffiQOiasS MATBIWL
YAOMN WELL COMPANY,INC. _ n• R I in,
Z:ampmy Name //� ,f _... 16.llNNZR CAMG OR T'UffiNG rotherassI rlaard-too
FRO2.well Construction Permit#: �T 7 T S M To Tm s su
List all appllcabla well amelrncllan permits r UIC,County,Stars,Yorimm.am) R (� It t in. 6,'� G
3.Well Use(check well use):
17.SCREEN
water supply Well FROM I TO I INAMEPER I SLOTt17T
tAMOUNT
DAgricultmal DMurricipal/Public n. R. In.
OGeothennal(Heatinf/Cooling Supply) t9midential Water Supply(single) R, R, in,
Olndustrial/Commercial (D_Residential Water Supply(shared) 1&GROUT
Dlm 'on DWells>100 000 OPD FROM TO MATERIAL.Non-WaterSupplyWell: R' 1 R' OI( v
DMominring DRecovery R ft
Injection Well: R fL C
DAqud'er Recharge DGroundwster Remediation l4
19.SAND/GRAVEL PACT( daonlicaDle 3
DAquifer Storage and Recovery ❑Salmity Barrier FROM TO MATZLIAL I EMPIACOUN'TMETHOD
DAquifer Test DStDrmweter Drainage tt R-
OExperimmtal Technology OSubsidence Control ft• it. C-
1
a
DOtotharmal(Closed Loop) OTracer 20.DRILLING LOG(aharD additional sheets if necessary)
t
DGeothermel(HeatinglCooling Retrpn) 00ther(explain under#21 Remads) PROM To nsstaaBnoN color,hardvev,roi0rvck aka sea eR
^ p R' 7S IL a
4.Date WrR(s)Completed: 1 02Z Wd "'I'A t O- $8 7 5 fe 00"'
5%Weu Location: Phone #3 — '1J- 3710 R. ft
Nn o tel s/I P t r�[e v a o AL n ft
FaniiitY/Owner— Noma Facility M#Cif appliesJOy4%1 aY R' R'
Physieel Addres%My.and Zip R R. i
/`i
Al e— 21,RAMd9YR L
Can* Paul bleotifieetian Nu.ON)
5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
(ifvrcB field,one lat/loag is sufficient) 22.Certification:
39 Al 31 3 N B•! 30 4) %F1 W 4 W q
6.Is(are)the well(s): Oermaneut or OTemporary Signedfre ofC ' ed Well Contractor Date
By jig ningthlrform,Ihemby certify then the we11(j)was(were)crostmded in accordance with
7.Is this a repair to an existing well: OYes or 01�10 ISANCAC UC.0100 or 1Sd NUC 02C.0200 Well Construction Standards and that a copy
If this D a repair jIll oul known well construction information oidexplah,the nature ofthe ofthls record has bean provided to the well owner.
mpab tender#21 mmarki notion or on the back ofthisfurm.
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 ORi-I is needed Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box).You may also atlacb additional pages if necessary.
drilled: G 24.SUBMITTAL INSIRUCIIONS
9.Total well depth below lead surface: -1 00 (D') Submit this GW-1 within 30 days of well completion per the following:
For=triple wells list all depth,or Vcmnt(emmpls-3 200'and?®100)
10.Static water level below top of calling: 0 (ft) 24s. For All Wells: Original firm to Division of Water Resources (DWR),
lfwater level casing,we above cas we"+• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter- (in.) Hit Off: .o3 o 24b.For IH.iection Wells: Copy to DWR,Undergound Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY L
24c.For WStar'upppy and Open-Loop Geothermal Return Wells:Copy to the
(ill auger,mtery,eeDla dices pmh,ate.) county environmental health depMtrnant of the cmmty where installed
U•
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over IDD DOD GPD: Copy to DWR,CCPCUA W
a Perrmt gram,1611 MSC,Raleigh,NC 27699-1 11
13a.Yield(gpm) is Method of teat: duel N 0 8 �.Z".Z.Z 1 / J
13b.Disinfection type: 70,G HTH Amount: OZ DATE SITE VISITED:
VISITED BY: •�B
Form GW-1 North Carolina Deparbnent offiuvirmuoental Quality-Division of Water Resources Ravised 6-6-2019