GW1-2022-10328_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information: r
., -If 1 y $14. ATER ZONC5
Well Contractor Name TO DISCRIPTION
ft. '0 NC Well Contractor CestificationNumber UTER CASING for multi-cased wells ORLINER(if applicable)
YADICN WELL COMPANY,INC. IFROM DUMEM I TRaCKnSS I MATERIAL
ft. rn.
Company Name 16.11VNER CASING ORTUDING eothermal closed-loo )
2.Well Construction Permit#: cq%g 3 FROM To ns�rorrrrvv IT3ICI0vrss AZL=TAT
List all applicable wellconstructlanpermits(r,e.UIC,County,Slate,Yariance,eta) ft s"L ft ``�� in.
3.Well Use(checkwell use): ft ft. `n-
Water Supply Well: 17.SCREEN
IRIOM . TO DLAMEI'ER SLAT SIZE 1711ICIONES5 MA r F RIA7.
❑Agricultural unicipaUPublic ft.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft
❑ m Industrial/Comercial ❑Residential Water Supply(shared) 18.GROUT 5
[]Irrigation ❑Wells>100,000GPD FROM TO MATEWAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. �-t� ft. �t Ln .2
❑Monitoring ❑Recovery it. ft. �1
Injection Well:
❑ ft. ffi
Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK Rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMMNTMETHOD
v ❑Aquifer Test ❑StDrmwater Drainage i
i1 ❑Bxperiments]Technology ❑Subsidence Control it
❑Geothemial(Closed Loop) ❑Tracer DRILLING LOG attach additional sheets if neeessa
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) zrxoM 7n DEstmtPllox comr,hatdaess,soiVraek aaq eIr
® ft
0 30 fL �-�d�'�' . .S� so I'
4.Date Wells)Completed: 8-31-Z 7- Well ID# r f - r 30 ft 30 ti• t ,° �, ;,i /1,2 -
/
sa Well Location: PhoneA
4l ���. t'9C� ' / 1
it. ft
r3�PwileR�e d Z. � �1�7,jQb� u,"l, i2r. c��d V4."2 7
.F caner Name FacilityIDfl(ifapplicable) ft ft 1 2 Pb
e, Physical Address,City,and Zip ft fL
21.RRIyrARKS
County Parcel Identification No.(PIN)
VYZ 6P0 rfiil11 6L el 4D ja.7 CE13�^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if-well field,one lat/longis sufficient) 22.Certification:
14 ®79 s' y '- ii W
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or °nN. ISANCAC 02C.0100 or 1 A NCAC 02C.0200 F7ell Construction Btandards and Mat a copy
Ifthis u a repair,fdl out known Well construction bformation and explain the nature of the of this record has been provided to the well owner.
repair•rmderW21 renrarkssectionoron the back ofthisfmm.
23.5ite diagram or additional well details:
ll.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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over in Remarks Box).You may also attach additional pages if necessary. <s
drilled: 44 t Z4.SUBNfriTAL INSTRUCTIONS
9.Total well depth below land surface: J� (ft.)
For multiple wells list all depths 1fdifferent(example-3()a 200'and 2Q1000 Submit this GW-1 within 30 days of well completion per the following:
110 ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
1D.Static water level below top of casing: it ( ) Information ProcessingUA 1617 NEC,Raleigh,NC 27699-1617
If water level is above casing,use"i'� ,��6 r/ �p ,vo3
11.Borehole diameter � (in.) Bit bff' c°io7 t 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copyto the
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY. 4d.For Water WeI]s producing over 100,000 GPD: Copy to DWI?,CCPCUA
13a.Yield(gpm) Method of test: A! f i!d�. hermit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: 70%HTH Amount: lid 0Z DATE SITE VISITED: °t1 •�� �t �
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VISITED BY:
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