GW1-2022-07484_Well Construction - GW1_20220810

L tCa�l�T -JIRUCTl0N REC (GW-1) For Internal Use Only:
'I.Well Contractor nfoi-Ination:
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��� _ .���`'! ��sti►�Ct✓1,� 14.WATER P.oNES i.
Well Contactor Name FROM TO DE.SCRIPI ONQPKATERML
.7 N fL Pqg fr R R
NCWell Contactor Cerficatiem Number15.OUTI�CASIIVG for niniti-cased we➢s ORLINER if a lYADKIN WELL COMPANY,INC. FROM To DMMm$R TfficrflvEss RCompaayName16.INNER CASING OR TUBING eothermal closed-loo2.Well Construction Permit#: FROM To DMMETER Tfficrmnss
Liar all applicable well construction permits(i e.EUC,County,State,Yorionce,efc) R 624
R IN in 5 tw a I evc
3.Well Use(check well use):
R fr. in.
Water Supply Well: 17.SCREEN
FROM TO I DMMETER SLOT SME I TMC0H0 ESS I MATERIAL i
DAgricultaral OMunicipaUPublic ft. fr.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft in.
DIndustriaUCommercial DResidential Water Supply(shared) 111.GROUT
DIrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well R 41 fr• 1401t P{ eouvre) i+
OMomrtoring DRecovery L4 ft a 67". ©-ct 61'bu1 eymc
Injection Well: R R
OAquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d'a licable)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
OAquifer Test ❑StormwalcrDrainage R ft
OExperimental Technology ❑Subsidence Control R fL
OGeothmmal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/CoolingRetnm) ❑Other(explain under#21 Remarks) FROM I To DESCK[rnOx cote hardness,soivrodc in sxr,etc
�c+ O ft. SO ft. Se
4.Date Well(s)Completed: -I Well ID# 0 d R '?ft Pin
5a.Well Location: Phone # _q/0i 3 ���3�q ft ft
(J,
dry=l1'h r rt /-e.o�,q e- [ ft fti 8
Facility/Owner Name Facility M#Cif applicable) ft. ft.
0
ft ft AUG 2022
Physical Address ' ,and Zip �T R R
I004is4l:0r'i PrOCWping Unk
Ad el t it 21.REMARIGS
Comfy Pamel IdentifreationNo.(P!N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
"3 3a LfL: ems' N YZI �� 33� S 3 W
6.Is(are)the well(s): Afermanent or OTemporary Signatale-ofCcrtffied Well Contractor' Date
Bysignbtg thisform,]hereby cert}fy that the wells)was(were)constructed in accortimtce with
7.Is this a repair to an existing well: DYes or AQo ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
IJihis Ls a re ofpair,fd1 out known well construction ftrformatlon and explain the nature of the this record has been provided fo the well owner
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction irdb
construction,only 1 GW-1 i�needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarlcs Box).You may also attach additional pages if necessary.
drilled: ` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 , i (ft,)
For multiple wells list all depths!f dfferent(example-3p200'and 2®1000 Submit this GW-1 within 30 days of well completion per the following:
10.5taticwater level below top of casing: �d (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level Is above casing,use"+" a �3 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off: •C 1 7 24b.For Injection Wells: Copy to DWR,Underground Injection Control (TUC)
Program,1636 MSC,Raleigh,NC 27699-1636 s
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.adger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: ``
24d.For Water Wells producrng over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield m r Permit Program,1611 MSC,Raleigh,NC 27699-1611 -�
(gp ) 3 Method oftest: q,( [i
13b.Disinfection type: 70%HTH Amount OZ DATE SITE VISITED:
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