GW1-2022-00186_Well Construction - GW1_20221216

CONSTRUCTION RECORD QW-13 For lntemal Use Only: !
�.-i.Weli Con-"tractor lnforaation:
®mil l/1 14.WATER ZONES s' I I
WellContisctor J=e FROM To I DIISCRTFTION
s7yJ4 . .r E. r R n Ss • .ss 3 .��e�
I ft
NC Well Contractor CertiScatianK mber
0[C 1 G ZQZZ IS.
OUTER OR1dIQER ifa livable
YADIUN WELL COMPANY;INC. FROM TO DIAMETER THIC[QVEss MATERLIT
CompanYName � in.
Z, +A 7v� V `S i T`�H 1 TUBING eothermal dosed-too
•� a �' '16.IlVNER'CASING'OB
s 2.W�l►Construction Permit#: Zc�2Z � FROM To DTAdIL�fER THICIINESs NbETMIAZ
Llsl akl6ppllcable well coitsY/uclloa peimus(ie tl1C Couniy, tale,Yaciance,etc) ffi f�~`�'
3.Well Use(checkwell use): fL ft.
titer Su l�Well: - - 17.,SU&M—
W, pP3/ FROM TQ DTAMT7Vn SLOT SIZE 7mclaass MATERIAL
❑Agricultural iElMunicipal/Public g, ia.
❑Geothermal(Heating/Cooling;Supply) sidential Water Supply(single) !t ftr fin.
- ❑lndustrtrial/Commercial OResidential'Water Supply(shared)
• 38.:GROUT
- [Hrrigation iDWells>I00;000 GPD FROM TO nuTEaIAL EMPLACEMENT METHOb&AMOIINT
i Non-Water Supply Well" � ft. qy P•
❑Monitoring 01ecovery • it aft.
Injection Well:
j ElAquifer Recharge ICI&oundwater Remediation i
UifB 19.SAND/GRAVEI PACK da linable)
❑Aq r Storage and Recovery []Salinity Ban ier FROM . - To MATERIAL irM A—IMENT TVIETaoD
❑Aquifer Ted OStormwaterDrainage ft. 8:
i
11l3xperimetital Technology BSubsidencc�Control ft. A.
❑Geothemal(Closed Loop) []Taer
. , LOG'atlah additional sheets ifnecessa'
ElGeotheimal(Heafing7Cpol1ng Betom) ❑0thBr(explain imder#21 RLmaft) FROM TO DFSCRTPTION color,hudaess,soVrnefcfypc6emm ,ric.
4.Date'V a(s)Completed: 'Wall M# Cl/ ft 3711 ft• q _
I 5a.W&Location: Phone # 76V-J,7�C. 7o1jr ]aft VIVO do.� arc. �! .
gk
Fam7ity/OwnerNeme F Y ( a ) _ ._ fLfL
AysicaIAddres%City,,aad2ip
' Z1.�
�r Panel ldentification'No:(m -
5b.Latitude andlongitudein degrees?minutes/seconds or decimaldegrees: •:. 11
l
(Twall field,one lat/long is sufficient)
22.Certification:
to
6.Is(are)•the well(s): ❑Permanent or OTemporary PORote ofORUJWell Contmdor Date
By signing thisform,Thereby certify that the we11(s)was(were)constructed in accordmtce with
7.Is this'a repair•to an existing well OYes or l No 1SA NC4C 02C.0100 or 15A NCAC 02C.0200 Well Construction 2andards and that a copy
i Ifthirisarepair,fdi out knownwellcanstrucdon.infomatknandWIdimthematureoffhe afthis record hasbeenpravidedtothewellowner.
repair under#21,remarks sectiotror on the back ofthisform.
23.Site diagram or additional well details:
I ' B:For GeoprobeMPT'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 TOTALNUMBBR of wells ,(add'See Over'in Remade Box).You may also attach additional pages if necessary.
drilled:
24..SUBMTTTALINSTRUCTTONB
� yy
9.Total well depth below land surface, i ft
For multiple wellslist all depths 1f&fferent(ermgple-3(a 200 and 3@1000 ( ) .Submit this,GW:1 within 30 days of well completion per the following:
10.Static water level below top ofcasing:_ 510 ? ft 24s. For All Wells;'Original form to Division of Water Resources (DWR),
I water level above casing, ( ) htformation Processiii 1617,MSC,Raleigh,NC 27699-1617
f g,use"+" g`Un , I
II:Bo rehole.diameter: (�) Bit Off. � � zab.'For Injection Wells: Copy to�DWR,Underground Injection Control(JUC
Ppgmn41636-Map.Raleigh,NC 27699-1636 )
AIR ROTARY
12.Well construction method: l'
(to' r tart'mWe,d reotpusb,eto) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
aogq,m county envt Mnmentai health department of the county where installed ..
FOR WATERSUPPLyWELLS ONi.Y• i I Copy WR,CCPCUA
24d.'For Water Wells producint over 100 000 GPD• Co to D
Penn t 1)rogmm6 I611 MSC,Raleigh;NC 27699-I611
13a.Yield(gpm) � Method oftest: l�crT°d�-iD.
70%HTH Oz � TE SITE'VISITED:
13b.Disinfection'type: a Amount:_ 51
d2o ii ii.� n r-
'Pr�r+a V15I7E - Dun-