GW1-2022-00235_Well Construction - GW1_20221216

�g3 C2ijCTiDN 'C Oil rcw-�� For Internal Use Only:
1.Well'Contracto, Information:
ZAe?Z! 14.WATER ZONES
Well dbVQwr Name PROM TO Da9at1PT10N
.� fL I.'16 �raaYff h 1G1'M
R R G
NC Wch Contractor Certification Number 15.OUTER CASING(for maltlosedwelis ORl, da Urable G
YADION WELL COMPANY,INC. FROM TYI DIAamraR THICA Ea MATERIAL.
R R ir.
Company Name CE( a,ek4 $2 26- g 9 16.]NNZR CASING OR TUBING eethersssal elosea-too
2.Well Construction Permit#: $i 3 FROM TO DIAIM^%TER TRicatreas `MATERIAL
List all applicable well construction penults(te.UIC Cowry,Slate,Parlance,etc) R �3 IL to In' r,
3.Well Use(check well use): R R. i-
Water Supply Well: 17.SCREEN
PPY FROM TO DLAMErER SLOT SIZE ®
I7A TCIOrF83 MATERW. ,
griculmral DMunicipal/Public R. R, ' in. CA
sidential Water Supply(single) R, R, to.OGeothermal(HeatineCooling Supply) re
Dlndushial/Commercial DRcsidential Water Supply(shared) 1&GROUT
DIrrigation OWells>100,000 GPD FROM I To�t MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: p`R• R' OMV I
DMonimring DRecovery R R
Injection Well: R R
DAquifer Recharge OGmundwater Remediation
19.SANDIGRAVEL PACK de liable
DAqujfer Storage and Recovery DSalinity Barrier FROM TO MATSRIdL 81bPIACEhmNr METHOD
OAquifer Test DStmmwater Drainage ff• R
DExperimeatal Technology ❑Subsidence Control R I [t.
DGeothermal(Closed Loop) DTracer 20.DRILLING LOGat6seb additional shells ifnectema
DGeothermal eating/CoolmgROurn) DOther(elcplain under#21 Remarks) I FROM TO DESCRIMONmmr hudaen,soiumea maha,err.
4.Date Well(s)Completed: 29, Well ID#ef
0 6 S3 R 2,150 R
SL Well Location: Phone # T35r-32o-0I11 2& R R Arlie
!f N IL30X R Awl"
acdity/OwnerN Facility M#(if applicable) R R .. ;.��... .
13 fa t61OW4, a.4 Mick&O'd A-etdZ� _ R it. e °
Physical Addrms,City,
,aand
Zip LQy)Uf(t NC 01W R IL
ic
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iat/long is sufficient) 22.Cer cation:
35 3-Z f07 N gl T.L " 3 y W
6.Is(are)the well(&): Aermanent or OTemporary Signature'eMErtified Well Contractor Date
By signing thoform,I hereby cerafy that the well(:)was(were)constructed in accordance with
7.Is this a repair to as existing well: Dyes or 00 ISANCAC 02C.0100 or ISANCAC 02C.0200 Well Construdion Standards and that a copy
If this is a repair,fill out known wdt construction information and"plain the nature of the af(his recordhas been provided to the well owner.
repair under 021 mmarkr section or on the back ofthis farm. 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 wnswction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Jo (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths/fdlfferenl(example-3Vo 200'md2®1000
10.Static water level below to of easing: 24a. For All Wells' Original form to Division of Water Resources (DWR),
P g ) VL) Information Processing Uni%1617 MSC,Raleigh,NC 27699-1617
Ifwater told is above casing,use"+" 9
Bit Off• 5 r I 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Il.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water SupD1Y and Open-Loop Geothermal Return Wells:Copy to the Z
(i.e.auger,messy.cable,direct push,era.) county environmental health department of the county whew installed
j
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodueln over 100 000 GPD: Copy to DWR,CCPCUA
/ rI- Permit Program,lfill MSC,Ralei ,NC 27699-1611 lF
13s.Yield(gpm) i 4% Method of test:
a IU OZ DATE SITE VISITED: / "IU '�]-/ h •••f
13b.Disinfection type: 70 fO HTFi Amount:
PT ire VISITED BY: V N,
•
�—�. na Deeartmevt of Environmental OuafiN-Division of Water Resourea Revised 6-68018