GW1-2022-06614_Well Construction - GW1_20220711

T1T�'u;1T1!&Ea CORD f GW— $' For Internal Use Only:
q -b r y r - .
h WeS I Contractor Infforruatton
14:WATER 20NE5:
wallContraotorName - -
DRUM TO DF.SC ON
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NC WeII Conhactor Cart ficationNnmber'. 15.:O1 TEEL II7G foraiul&-cased wells ORLTNER �f a licahle
YADIaN WELL,COMPANY,INC .TROM TO _ lilmmm TmaK IFss MATERIAL -
ft. ft: in. r..
2oP Y TilBING eoffiermal rlosed�loo
Well ConstructionPermrt# p�^✓�1J iP� 16.Il�IlVERCATO SIlVGOR D1A�o TSICmVm5 MAIERIAI.. FROM
List all applicable well eonsrructlon permits(e:UIG County,State,Yai•(cnc-e,,etc) - ft.
3.Well Use,(checkwell use) ,. f ` ft - in.-
Water Supply Well 17.SCREEN
'mom TO DIAMEM- SLOT SIZE TSICnNIESS MATERIAL
I7AgrictiItrraI,i ❑Municipai/Public
❑Geothermal pF qe ng/Cooling Supply) ❑Residential Water Supply'(single),
O�n Commercial ❑wel EiResidential Wafer Supply(shared)
18:GROUT
s>100'000'GPD .FROM -TO 'MAT! UAL EMELACEMENTMETHOD&AMOUNT
1�Ion-Water Supply Well:' Tt
❑Monitoring_; A _ l7Recovery ! i� T . �+: - Jh -
Inlectiori Well, . ; /Y
❑Aquifer Reoharge' ❑Groundwater Remediation _
rStordge endRecov [7S Barrier .!SAPID/GRAVEL`PACK'zfa livable
❑ QlllfEA erY FROM "'TO MATERIAL - EMPLilcnamwre METHOD
❑.mi.ii i•Test ,❑Stormwatel-Drainage '
❑ enmental Technology ❑Subsidence Control ft ` ft.
[7Geothemial(Closed'Ioop) UTlacer 20.DPJLIMGLOG,attachaddition,shicts'ifiiece sa -
" FROM" TO "_ DES(3tIPTION cc or.Lacdae9•soa/mck c, • Mize,ct¢
❑Geothermal'(Heating/CoolsngRetmn) ,❑Other(explain under#21 Remarks)., . fti.
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4 Date Wells)Completed: Z We11ID#AAA 0- y ` I r� t�
WellLacation: Phone #33�S- c�q_ 2-74:5' -
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Famlrty/OvmerName - _ $acilityID#(if cable)
- -- - - •�. _;4w q,—
ft. - JUL-1 1-2022
21,RNMARKR
Cotmtp' 1 atoel we mcat6in.'(PIID ,n .
5b Latitude and longitude•in idegmes/minutes/seconds or decimalAggrges:
(Xfw I Feld,one lat/ioagis'mfflciicnt) s� 22.Certifica_tiont
W �
6.Is(are)the vrell(s) DWermaneut or ❑Temporary a of id Well,Commior_ 'Datei��/ Ey slgning thtsfomt,Thereby cer*fhat the wells)was.(werq)cwrs6pcted In accordance with
7.Is thli a repair to an existing well: ❑Yes or @Ro JSAKCRC 02C.0100 or I5A=C 02C.0200 Wifil Constmcilan SYmrdardr and lhai,a ropy
If this is c repair fill ouf kdown well construction utJormotlon and eiplain the Hutto z of the is- eard'lrasbeen provid a the•weU owner
repair under321►emarkssection or on the back of.th4 form.
Z3..Site diagram or,additionalweii details:
8.For GeoprohetDPT or Closed=Loop Geothermal-Wells having the same
You•may use theck'!ba of this page Ito provide additional well rorstruction info
construction',only l GDP 1'is needed. Indicate TOTAL NUMBER of wells �(add'Sea Over in Remadm Box).You,may also aftall additional pages if necessmy.
drilled .. 24. 1HIARZTAL INSTRUCTIONS
9.
Total depth below land surface: 7 d10 A) ;Submitahis.GW=1�rithin 30 da s of well,completian;per thefollowing:
For multiple wells list all depths fdifferaw(example-3Qa 200'and 2@1..001 - y
10.Statiewater level below top of casing: SO (ft) 74a• For All Wells: Original fora to Division of Water Resources (DWR),
Ifwater level Is above casarg,vse'+" Information Processing Unfit 1617 MSC.'Raleigh,NC 27699-1617
D Bit Off •:�/ ® 24b For Inlectzon Wells:Co to I)
11.Borehole diameter CM-) PY WR,Underground Injection Control;(IUC)
Program,I636MSGRaleigh,NC'27,699.1636
AIR ROTARY
12.Well construction inethod: 24c.For Water Supply and'Open,Loop Geothermal Return Wells:Copy to the
(i.e.suge,rotary,cable,direct PdA etc) county,environmental health"departutent,of tht county where'instalied
FOR WATER SUPPLY WELLS ONLY 24d.--For Water Welis,producina over 100,000 GPD:,Copyto DWI?,CCPCUA
13a.Wield Method of test• i O') Permit Program,1611 MSC,-Meigh;NC 27699-1611" p
13b.Disinfection type: 70%HTH Amount:. !J, OZ DATE SITE'V(SITED: ',� y' 23' l 99
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