GW1-2022-06625_Well Construction - GW1_20220711

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Vr- L tCO NSrCRECT1ION RECORD ('GW-D For Internal Use Only: v
I.Well Contractor Information:
19.WATER ZONE
Well Contract r Name FROM ft, TO ft DESCRIPTION J
�57�-� /.7 a tSZ' awl, �s T r� SUIT, 7�
ft. ft
NC Well Contractor Certification Number 15,OUTER CASING for multi-rased-v? ORLINER d a livable
YADIQN WELL COMPANY,INC. FROM To DIAMETER Tfficlsrn ss MATEALIL
ft ft in
CompanyNrme J.� 1'6.ETM CASING OR T[1BING( eothermal closed-loop)
2.Well Construction Permit#: Z 6 L�y 10 / FROM TO DIAMETER TMCKNrss MATERIAL
List oil applicable well constructlon permits ri a.EX,County,State,Variance,eta) 9 ft G. in.
3.Well Use(checkweil use): _ ft. ft. in.
17iWater Supply Well: FROM
SCREE PI
PPY ITtOM TO DIAMETER SLOT SIZE TSICIINESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating(Cooling Supply) Residential Water Supply(single) ft, ft. in.
❑Industrial/Commercial []Residential Water Supply(shared) iB.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 1/ ft. „.L+Gti; 11� v v�r�
❑Monitoring ❑Recovery L/ ft a / ' ft.
Infection Well: R, %
❑Aquifer Recharge ❑Groundwater Remediation
79.SAND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery - ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop), ❑Tracer 20.DRILLING LOG attach additimW sheets if necessary)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) asoM xo DESCRIPTION(color,hardness,suiVmek a size ecc .
ft ft ' •
4.Date Well(s)Completed: 5'18—22, Well ID# 4d-9 Z 7. ft. [,S' ft �/Q' , f7�� • ��
14-
5a•Wen Location: Phone # ��7�3 � `� 4(3 (os-a�
Asa ft ��603 I -
Facility/OwnerName _ FecilityMff Cif applicable) fL ft O^'
Physical Adds,City,andzi� ft, ft. ,rh_-a �ry'1?ROCS 1�� ► t-
21.REATARKS
"�b �'w
County; Puce.IdeatificationNo.(FIN) D // �"QL°ve e Q o r-ke-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Oix t.v,,-�/r �S• '7f`/o a a(•A
(ifwell field,one Iat/longis sufficient) 22.Certification:
N �1/ 3 y =2�,8'3 W ;Ci S-��'•��as
tor Date
6.Is(are)the well(s):Aermanent or ❑ Si re of Ce • ed Well Contrac
Temporary Q
Bysignumg thisfonn,l hereby certjfy that the wall(s)was(were)constructedin accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15ANCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction LStandordr and that a copy
Ifthis is a repair,fill out known well construction urformatlon AdLplofn the nature of the ofthis record has been provided to the well owner.
repairrmder#2I remarkrsectian or on the bask trfthisform. 23.Site diagram or additionalwell details-
B.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box),You may also attach additional pages if necessary.
drilled: 24.SUBN rrAL INSTRUCTIONS
9.Total well depth below land surface: �7'd (ft) Submit this GW-1 within 30 days of well completion per the following:
Formultiple wells list all depths lfdffferent(example-3 00'and2@1005 l
� ) Isla. For All Wells: Original form to Division of Water Resources (DWR),
;1D.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
Ifwater level is above casing,use
v Bit Off 24b.For Injection Wells: Copy'to DWR,Underground Injection Control(IUC)
11,Borehole diameter: 4L(i.•) program,1636 MSC,Raleigh,NC 27699-1636
12.WeIl construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pro du c.uI over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) �y Method of test: qfl` I
c '�'`1 3"4
13b.Disinfection type: 70/o HTH Amount: (Q /► l OZ DATE SITE VISITED:
„__ �. . - -- - -------- VISITED BY: (/8