GW1-2022-07481_Well Construction - GW1_20220810

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Foi`Intern Use Only:
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1.Well Contractor Information:
14.WATER ZONES It M
Well Contractor Name FROM TO'• DESCrtIPTIUNS
S�.sG Prn
NC Well Contract�ur•Cei ifieation Numbs $'�' " r
IS.OUTER.
INnlh 5asea wingOR<LINERr if
YAOKN WEECOMPANY,INC. FROM A mDIATER &THIG 8&",a G,*ciMAti1T8E R1ALV
,..t;- • ft. - V III .f,jY- Y"S`
Company Name 1 " a taa
16.EVOM CASING QR TUBING "tLermal;rldsell=loo"
2.Well Construction Permit#: L ��O PROM Dr• � st Tffictavrssl�l iM'aTERiAz,�r (O
List all applicable well construction permits(4e C County,Stare,Yarfance,emJ ft ?SOgZ�GCK Se'!ct'i ='1
3.Well Use(check well use): 'iai
Water Supply Well: 17.SCREEN
FROM TO 3pIAME1ERle 3MOT�SMVIII#THICIQVSSS�AMATERIAL�
❑Agricultural ❑Municipal/Public ft. I ft
❑Geothermma](Heating/Cooling Supply) Residential Water Npply.(single) ft it in4 �
Olndustrial/Commercial ❑Residential Water Supply�(shared) I11.1CROUT F� ~
❑ligation ❑Wells>100,000 GPD .FROM& :•T0`; *MATERIAL �EMPL'ACEMEIVT,METHOD�BTAl4IUIINT�
Non-Water Supply Well: 3 itr ' " its" 1O'e FYIN
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19?SANDlGRAVELkPACK da"licable
❑Aquifer Storage and Recovery gSalmity Barrier FROM; nTo IMATERIAL. lEMPL'kCEMENI'rMETSODI� -�•�
❑Aquifer Test" 0Stomrwater Dramagg
❑Experimental Technology. - ❑Subsidence Contiol
❑Geothermal(Closed Loop) ❑Tracer ZO;DRQ,LINGIAG,it ch;additional sheetsifaeeasa
❑Geothermal(Heating/CoolmgRetum) ❑Other(explain under#21 Remarks) FRoMii• txolalt &*DPSCRUIn0N,`FaIaMEiRd�aeuToa/mrlr-
t s ' s 0., s NI ft 't� t�1�_I p' Inc. 4►
4.Date Well(s)Completed: I 1 s a? Wen]D# � � F'�?Eft g {s3IS
��ft
Sa Well Location:
Phone
# 33 Qf $ft w d
Facility/OvvaerName Pactiliity MA(ifapphcable) ft
Physical Address;6-ty,'and Zip ft
.V GV'ti 2L REMARKS
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County Parcel mentificationNa (PIN)
vqs- a e•-
5b.Latittide and;longiinde in degrees/minutes/seconds or decimal degrees: *�
(iEwell field one IaU[oagis sufficient) 22.CecfifieatioII
Sr of Contractor ,
6.Is(are)the well(s):�ermanent or ❑Temporary ail Well•tea
Eysigni ngthfs ,q t ,
,A,.,, form,3hereby�cetilfy thatwthe wYell(s)was(were),caasbvchd fn:accordance wffh
7.Is this a repair to an existing well: ❑Yes or dryo 15ANCAC 02C.0100 or I5A 1VCAC 01C 200*171 Constauction SYond `d"ih"at py
1f this is a repair,frill out kaawn well construction information meezp/afn the nature of the of this record has be provtdid►01he we
repair under#21 remarks section or on the back ofthis form. r ^'
23.Site diagram or ad'Aonal wellidetail`s
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pag'etoypmtnde additional well construction iafo
construction,only 1 GW- is needed;'Indicate TOTAL NUMBER of wells (add'See Over,in Remy Bo"kx)"�Y u ma"ay°�aisoadditionat;pages if necessary.
drilled.,
3Oa 1. 24.SUIBMITAL INSTRUCTIONS
9.Total>well dE th below land surface: ' t
For mulive wells list all depths Ifdifferent(example-3(a)100`and 2@100) �R) Submit this GW-1 Within 30 days of�wC In ICU n per the following:
aD 24a. For All Wells Original forFn. Division of Water Resources +WR,
r0 Static fYater level below top of casing: ft (D )
J v;•merlevrl is above casing use"+" ( Tnfonnation Processing Un1617 MC., ei , Cr27699-161+7
e' Bit Off: :7� < J40 7Ab.For Yniection Welts Co toD 4
11.Borehole diameter: (in.) pys WR,Underground Injection Con 1(IUC)
Program,1636 MSC RaleagS;�NC 27699 1636
AIR ROTARY aL " 'G
12.Well construction method: 24c.For Water Supply and Open Loop G othermal;Return Wells:Copy to the
(i.e.anger,rotary,cable,direct push etc.) county environmental health:departxitent of the county wheretinstelled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pi-oduciuR tiy r 100 Of00 GPD �Co fo D
.-: py WR,CC?rill
` Permit Program,161'1 MSC;Ri leigif.' 27599 1611 ,
13a.Yield(gpm) f�^r' Method of test: S✓ _ k�
r JP_• 70%HTH _ �3 07 ;T` �F`JiiTED S .L� t
13b.Disinfection type: Amount: .,
v9 ;..o VISIT Y