GW1-2022-00175_Well Construction - GW1_20221219

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -{�I
1.Wdl Contractor Informatiou: y
0A1-f # 4)1V4 -, 14.WATER ZONES
� t_i �T.T lROa1 R 70 R D7SCRIPMON WeO Contractor Name
' c.,.
3o364 oFc1 92022 ft R �`
NC we➢caananmrceidsa.tionN�hc • N
::P.�r.1.,1 7ROMv1'SRG18[PiG'faTmn6-a¢d wells OALBUBRd Uuble 1 ,
YADION WELL COMPANY,INC. - U6E18R 77nf�eass MA77tR7AL
R .
2.Well N®e 16.INNER CASING 08 TUBING eotbermal closed-luo Z
2.Well Constrrrctlos Permk#:�( � r'�� Za 22 FROM aD rubtrTan TMCICNUS MATZHA
7.1st oll appl/oaDle well canrhuctlon permltt(La UIG Cmouy,State,Yarimrq ete) R Q R i ra 1ei11 -
3.WellUse(checkwelluse): R. ft.
te. JY/
Water Supply Well: V.SCREEN ^
FROMf TO I 1441dr Fy I BUM= I TRtarnass VATzR141 Y
❑Agricultural OM/unicipal/Public ft. ft. in
OGenthermal(Headn)Cooling Supply) ORfiidential Water Supply(single) R R.
Dlnilustial/Commercial DResideiltial Water Supply(shared) Is.OROUT
DIm 'oa OWells>100,000 GPD _iRT—ERIAL FASPIACFMSNT METHOD a AmoDNT _
Non-Water Supply Wall. 0 ft. �7 R G �Z
DMoniunring DRecovery R R
Injection Well:
DAquifer Recharge DGrmmdweter Remedistion R R
DAquifer Storage and Recovery DS SAFID/GRAVF.i.PACE as ale
elinity Beau FR R oeI I an MA78arAL aM87wceMmNT METaoa -
OAquiferTest OStvrmwater Drainage R R
DExperimental Technology DSubsidencs Control R R
DGeottuumal(Closed Loop) DTlacer 11L DRUAIMG LOGathu3 additional&beef.ifnerma
DGeothmmal eatvg/Coo]ingBehuD) DOther(explamunder#21Rermda) I TO Drsr ux eslo hs,aeea,reaha
p © R 36 R S t'
4.Date Well(s)Completed: � L Wall DNf A P-2q-7 3 L R tt t R G iw
Sa.Well Location:on:
one #334-%.3'g^,t, R 7sR Se•
Fwlity/OwnerNeme F-litylDB(if9pheable) R R
�L277 ffurwr RA R R
Fhysmal Addmss,Qtr.and Zip —� R H.
1 k L' 21.REMARES �r
CountyPsmd TA,fir fi,No.(PIN) ya t f 6A, /
5b.Latitude and longitude in degmes/minutes/seconds or decimal degrees: 0x ytUt)!
(if wall field,me Woagis a$eient) 22.CertiBeation: .279"tu Elva li
U a 0 B . 2.i-1 N 8b ysl. .riS W 40Ki j' )if� //- 8.2 Z
6.13(aro)thewell(s): 4e smeut or OTemporary Signature of Certified Well Coubaetar Dabe
By sign 6fg thlsform,Ihereby cerrifyihat the well was(werel conWcled1,occord .with
7.Is this a repair to an existing well: OYes or 17No 15A NCAC 0ZC.0100 or ISd NCAC 01C.0Z00 3Fe11 Construdim Stmudards and that o copy
lfthir is a repalrfdl out Anown well construction gformation and erplabh the nature ofthe, offhbr record has been pravided to the well owns,.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprube/DPT or Closed-Loop Geothermal Wells having the same You may use the beck of this page to provide additional well crosta elm info
construction.only I GW-1 iq needed Indicate TOTAL NU2%MER of wells (add'See Over is Remerla Box).You may also attach additional pages if necessary.
dulled: ! 74.SUBMTTTALL INSTRUCTIONS
9.Total well depth below land surface: O V (R) 0 h i Submit this GW-1 within 3
For multiple wells list all depths lfdrfmvd(erampla.3(�700'mud.2@1007 days of well completion per the following:
10.Static water lewd below top of casing: 6 d (1t) 24a. For ALL Wells: Ongmal loan to Division of Water Resources (DWR),
jy
Ijwoter fever is above rasing ire"+• '/ Information processing Unit,1617 MSC,Raleigh,NC 27699-1617 n
11.Borehole diameter: ak (in.) Bit"AX,?,r 74b.For Ltiection Wells:Copy to DWR,Underground lnjection Control GUC) V/
Program,1636 MSC,Raleigb,NC 27699-1636
12,Wall construction method: AR ROTARY
24e For Water Supply and ODea-Loop Geothermal Return Wells:Copy to the Q�
(u.n roger.-bay.cable,direct pmb,eaJ county envhronmental health department of the county where installed (, \
FOR WATER SV"LY WSLIS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
. ermit Program,1611 MSC,Raleigh,NC 2769 -I I l
13t.Yield(gpm) / GI i 4- Method of test: !�� ql/ P
13b.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED: IF• L 9- 1 x-
Pri rn• - VISITED BY: