GW1-2023-01822_Well Construction - GW1_20230223

WELL+CONSIRUCTIION RECORD (GW-1) For Internal Use Only:
cll Contra::tor information:
,..----- a H4, HC Sr U 1,�/l 19.WATER ZONES ^
Well Connactor Name FROM TO DESCRIPTION \ -
3� 3 � ,4 ios-o ft. /vra fr. �
fr, T
NC Well Contractor Certification Number 15.OUTERCAO .
NG eilR YADKN WELL COMPANY,INC. FROM mDIAMTER THICKNELINER ifa �
MATERUL
ft. I in. T'
Company Name /� 16.INNER CASING OR TUBING eothermal closed-loop
t�
2.Well Construction Permit#: d YJ 13 W FROM TO DIAMETER I THIcicros I MATERrA1.
List all applicable well construction permits(i.e.DIC,County,State,Yariance,etc.) ft. 3.9 ft 6 m• S A
3.Will Use(check well uie): ft fr. in. v
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIM TSICKNItss MATERIAL
❑Agricultural ❑MunicipaVPublic ft. ft.
❑Geothermal(Heating/Cooling Supply) Oesidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM To MATEldokL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. ?y
❑Monitoring ❑Recovery it fr. 1u V
Injection Well:
❑Aquifer Recharge tU ;)� LOGroundwater Remediation 19 SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery _0Sali4*,Barrier FROM TO l- MATERIAL EMPI ACLMENTMETHOD
❑Aquifer Test ''✓,r,'� li]Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Kelton) ❑Other(explain under#21 Remarks)
FROM I TO h DESCRIPTION color,hardness,soiVrock 'a sae,ete
Jo ie2
4.Date Well(s)Completed: '`f-.29-22- /�,Q n ft.Well ID#r 1` !0 '7 30 BA&rbfr-
5a.Well Location: Phone # 33G'rfd 7, 4a o 0 Wn Ab'74-s. t, Alf w
/fie h Ce4- Jo 7.r
Facility/Owner Name Facility ID#(if applicable) //°J ft /z()t I [
�-/5 7 0 CG`I e C y'c e ik 41 C_ ykQ/7 ft. it
Pbysical Address,City,and Zip W MOO e OO ft ft.
+/ es 21.REMARKS /
County C Parcel Identification No.(MD /�%w v / r �2 /�/ T+/ let
f ZY UU i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification.• �r�V Nib, r)- Urw /UUv` yq
N R'
6.Is(are)the weli(s):Xermaneut or ❑Temporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out]mown well construction informationAdpl.in the nature of the of this record has been provided to the well owner.
repair under#2I remarks section or on the back of this form.
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 construction info
construction,only 1 GW-1;s needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: L 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: le2
For multiple wells list all depths Ifeliffereni(example-3@200'and 2 100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: /p (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level Is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: co (in.) Bit off: - -9 3 R 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:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed -
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producing over ROD 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 'A . Method of test: 'e/ ' I > -
70%HTH 7z OZ DATE SITE VISITED:
13b.Disinfection type: Amount: ^ ` 3444
UTi('P'
VISITED BY: V/Y
Form GW-i 1 Quality-Division of Water Resources Revised 6-6-2018