GW1-2022-06931_Well Construction - GW1_20220603

WELL CONS TI R UCTION RECORD(GW-1) For Internal Use Only ;; J
1. eVt*ll Contractor Information: Vti
l A- 14WATER,
LLn J4�as +�
f WATER 2ANL+S
FR0111 . i, TO SDIISCRVTION
Well Contractor Name
�oZ
NC Well Contractor Certification Number Is,OUTER
FROM CTAoS 1Kd G form Dhned•;we
R R3rf a Gentl
YADKN WELL COMPANY,INC. e
taMplEgiAL !►
ft.
Company Name 3Yo-7 �.
16.n%M CABMG OR,TGIBINGi"tbernmlclosed`-too
2.WellConshuctionPermit#: a4(,9SS FROM ro: !DrUffinsR &TMC-M sssalrfanscTLrRrAL
,.»,.. . .�t in
List all applicable well construction permits(r a Ul ,County,Slate Yarfance eta) -� & 4ft�
,# G /ft pR' V
3.Well Use(cbeckwell use): 2; .ia.
Water Supply Well: r 17 SCREEN
FROM TOAAr". IiDTAMECER�Y t65I OT;SIZSir�TIDCIQYII55�1MITF.MIi1Lr
❑Agricultural bkunicipaVPublic ft v
❑Geothermal(Heating/Cooling Supply) V.6sidential Water Supply(single) P ft r'x ft. is
❑IndustriaUCommercial pResidentia]Water Supply(shared) 418TGROUT"
❑Irrigation l7Wells>100,000 GPD '§FItoM &Toll IMA7EItTAL' �EMPIAGEINENTiMBTSOD,�f,urromrr�
Non Water Supply Well: z •'Q ? 3 it. (.11'.v.� N.rar� .Z
❑Monitoring Recovery
Injection Well: IL
❑Aquifer Recharge ❑Groundwater Remediatiori h
AMR 219 SAND/GRAVELPAQC,'d.a lceble
❑Aquifer Storage and Recovery ❑Salinity Barrier trrROM 8To IMATEMiAi fLMpI.�C¢t�HT�71D Tgoa1
❑Aquifer Test ❑Stmmwadr Drainage
I 1w 14`•.` L
❑Experimental Technology ❑Subsidence Control 1^ "ft it
❑Gcothernral(Closed Loop) ❑Tracer , . ^'• 6fi0sDltII;LIlVGIOG?atfarlLTs'dditi n ll'shxtsif;aecssa.:
eu� r&FBOM RrTO tDIISQtYTION enleFlhardaease�oVroek;
❑Geothermal(Heatmg/CoolingRetum) ❑Otlrer(cicplam/�unA�der..#21 Remarks) ® eO1 1 C
weum# litsl/a 9 , L 4.Date Wells)Completed: $ (� ��' W W +CAf1�
Phone # � `• �`
5a Well Location: 33��:Sa4�/3�0.
M
l fr►o rl4►rl �
Fam'lity/Owner Name Fa ttyIDfl(ifepphceble) ' mufti
1 `}o -00cir11s m CTAOck
Physical Address,City,and Zip 6n4
12L4RRMARICS )L )r
County ParcelIdereficationNO.(PIId) 'r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degr, 4.64
(ifwell field,one laUlongis sufficient) 1 22�'Certificatiott .
350 59,34$ N 80` 30- 3` 9
6.Is are the wells: 5iKermanent or ❑Ten or Srppatnr of'i &'l W 11'Gomiactor
Bysignbrgihrsform=lherebyart�ythafthewell(sJ as(were)canstrucfedinaceordmrcewith
7.Is this a repair to an existing well: ❑Yes or Ioo 1SANG$C�-f, '01'0'O or lSArNCilC 01C.020D Ii'dl Construction SYmidards and lhat.a ropy
If this is a repair,fill out known well construction biforma)ion and explain the nature of the of llili r'eeo dhas been prov/ded, the we l owner
repair render#21 remarks section or ch the back of this farm,
23 Site-dragram:or aaamonalweu details: (U
" the back of this age to
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same "You-m use
�.,. �' P provide additional well conshatctioninfo
construction,only 1 GW-1 is needed, Indicate TOTAL NUMBER of wells (add'See Over'vin:RemarlsBcx).You;may also attach additional pages ifnecessary.
drilled:, 24 SUBt�rl rr eT.INSTRU.CTIUNS ��
9.Total well depth below land surface: 3 (ft) 'gubitabrs GW-1 within 30 da s of well coin letlon er th o o,
For multiple wells list all depths iire Brent(=ample-3(a]200'and2®1001 m y P P g�
10.Static water level below top of casing: e7 O (ft) '14a. For llllWells: Original form to Division of Water Resourus (DWRj,
lfwater level is above casing,use"+" InformationoPmcessing Unit,161?7,MSC,Raleigh,lJC Z7699-161r7
�> Bit Off: 70:Tor Iaiecuon Wells:Dopy to DWR,Und
11.Borehole diameter: (in.) erground Injection Control(N�
PrDgram;�1636 VfSC;Relwgh,NC 27699-1+636
AIR ROTARY 1
11 Well construction method: 24c For Water,Supply,and:Open-Loo TGeothermal, BRUT
Wells:Copy to the
(it.auger,rotary,cable,direct pursb,etc.) co � enviffln—miditEPWaltlilddpartolent a eou`nty vvheie'tiiistilue'd
FOR WATER SUPPLY WELLS ONLY: ,} 24d For.W,ater Wells producioajoyer 1001000 GPD:Copy to DWR,GCPCUA
'4PermitPiograrn,161IrMS9,Ralet9h,4�NC+27699 It! '1}1 j
13a.Yield Method of test
/c Alt
70 H
p>Z DA7E SITE�II5ITED fa i
13b.Disi�nfecttoii�type: c HT� Amount:
In-4