GW1-2022-00169_Well Construction - GW1_20221219

CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informntion:
14.WATER EOPM
WtITQm1aemrN a FROM I To I D1t8LREMGN
S 7d—A ° R R / e��sR�O R fL //aft �.•'�/ ,1
^ it I e
NC Well Connector CartifieatineNumber 15.OUTER CASDIG farshivlfi-u wrBs OALINER da Gcable
YADICN WELL COMPANY,INC. FROM in DIMSCRR Tluam s X&TRRiAL
ft. it,
..3V in.
CompmyNemw t'I'tz) '3 p 16.1NNM CASING OR TUBING dm mral dosedaoo
2.Well Construction Permit#: (A 76A FROM I TO DtAsulaR 't'1Qcearmas MATISMAL
Iln all applicable well construction pmmits(te.f11C,Co",Stair,Var(ana,eseJ R' 4� IL .n T t- �IV4 I P 1/C.
3.Well Use(check well use): R R sn.
Water Su well: 1 oom
PPh' FROM To oussEl'et I slmam I r®mOvass MA
OAgricultmnl OMhmicipal/Public D. 1 H. In.
OGecthermel(Heating/Cooling Supply) Uldsidential Water Supply(single) R I rt. Ila
Olndvshial/Coaunerciel OResidmtial Water Supply(shared) 15.GROUT
DIM9111011 OWells>100,000 GPD FROM TO MAM"AL Eh21ACKMXNT METHOD A AMOUNT
Non-Water Supply Well: Q ft • ft' Oa/IA/
OMonimring ORecovery •IL 3/ R' M-SI J
rwev
Injection Well: R R
OAquafer Recharge OGroimdwater Remedistion
19.SANDIGRAVEL PACE:de liable
OAquiler Storage and Rccavery OSalmity Barrier FROM TO MAT>Dhw. EasmAccamitTMRTRon
OAquiSe Test OStmmwater Drainage R R
oRgmrimental Technology OSubsidence Control R R
OGeothermal(Closed Loop) OTrecer 20.DRnTTNG LOGaRach additional sheet,ifnecessaryl
OGeeWermal(Heating/Cool'mg Rehm) OOther lain under#21 Remed® mom
I To I �saehrn�soN eomx LoNvev,so,Vmra sas eta
4.Date Well(s)Completed: 8-02— Weum# A• V/ 2�3 rR jW fL
IY - $ Pap' R �
rew w
5a.Well Location: Phone #
R a
n2„re v So rva eY.! ' - . .
Fe -*IOwner ame FaddyM#ffgplirable) R R
So Crl IF.phr�aVt to%1� R a
Physical Address,City an lip d
8 R r1 9 Z072
l I�lTS 231-REa1ARRH U
Cc"� PamdlA, cation No.(PIN)
5b.Latitude and loagitade in degrees/minutes/seconds or decimal degrees: — —
(ifwa➢field,me Int1bagis suffident) 22.Certification:
0 G. 11'/ig x 000" J 2 frY W Q" &7 //-/o .ms
6.Tr(axe)the well(s): El6mnnitat or OTempotvey WO ofCmt&td Well Cwhacmr 'Date
By signingthisform,I hereby ar*that the well(s)was(were)comrucoidIn accordamewith
7 Is this a repair to an existing well: oYm or MNo 15d NCAC 02C.0100 or ISA NUC 02C.0200 Well Construction Standards and that a copy
y,hbr h a repair,fell out blown well conshumon bfarmation and erplot,the nature of the q'Aft remrdhas 6ee n provided to the well owner.
rquirsaider#21 remark section or an the back ofthisfo m. 23.Site diagram or additional well details:
S.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
construchim.only I GW-1 is rj d. Indicate TOTALNUMBBR of wells (add'See Over'in Remmfa Box).You may also attach additional pages if necessary.
&Mcd: 24.SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: Z� (n) Submit this GW-1 within 30 days of well completion per the following:
Form ilip/ewells list all depths/fdifferml(example-3@200'md2®1003
3, (�) 24a. For All Wells: Original fora to Division of Water Resources (DWR),
10.Static water level below cap of teeing: Iafmm an Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is obone casting,use"+"
Bit Off. Underground
S•9 24b.For Injection Wells:Copy to DWR,Undergrod Injection Coatml(IUC)
11.Borehole diameter: 6 (110 Program,1636 MSG Raleigh,NC 27699-1636 _
12 AIR ROTARY Well construction method: 24c.For Water SuvDIv and Open-Loop Geothermal IteturD Wells:Copy to the
CL& W.many,wbb%d¢eot peat,,ate.) candy envronmentsl health department of the county where insulted C
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduchi over 100 000 GPD:Copy to DWR,CCPCUA
l PerrmtProgram,1611 MSC,Raleigh.N 27 9 -1611
13a.Yield(gpm) /s Method of teat. -rp'+�_ S
13b.Disinfection type: 70%HTH Amount: / OZ DATE SITE VISITED:
Z—LZ
^^• — --_ VISITED BY: W/