GW1-2022-08462_Well Construction - GW1_20220411

WELL e-ONS TIRUCTION RECORD(GW-1) For Internal Use Only:
l.'Well Contractor Information:
P
JAJ 14.WATER ZONES
Well Contractor Name APH I r-202? FROM To DESCRIPTION QA
7/ 7 1 3-ft'
.)-5 d% ft
WC Well Contractor Certification Number -is,_0UTMCASING(for ulti-case I d*ells)OR LINER Cif ap livable)
YADKJN WELL COMPANY,INC. FROM I TO DIAMETER TMCaCMS MATERIAL
Company Nam. 0 a..$(e '3 ft. I ft. � in.
16.INNER CASING OR TUBING eotlrermal dosed-loop)
2.Well Construction Permit#: FROM I TO - DIAMETER I THlcmirss AILATrJUAL
List all applicable well construction permits(ra.IXI;County,State,Varlarim,aw-) 41 f'-- Aa 7 ft 'n- 1,5P P,--;�
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: -mom TO DIAMETER SLOT S=. THICIMSS MATERIAL
Eftricultural [IMmicipal/Public ft. ft, - i1a. 4
DGeotharmal(HeatingtCooIing Supply) asidential Water Supply(single) ft. ft.
[Hudustrial/Commencial DResidential Water Supply(shared)
18.GROUT
DIrrigation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT ATETHOD&AMOUNT
Non-Water Supply Well: ft. ft L Al JJ yse..O:
DMonitoring ORecovery ft. Be-i -slu
Injection Well:
ft
&
OAquifer Recharge EiGromdwatrr Remediation
OAquifer Storage and Recovery -OSelinityBarrier 19.SAND/GRAVEL PACK ffamlitablp)
FROM TO MATERIAL rAXPIA -MNTN=1OD
DAquifer Test ❑Strirmwater Drainage & JL
OExperimental Technology OSubsidence Control ft fL
DGeothermal(Closed Loop) Mracer 20.DRILLINGLOG(attach additional sheets ifnemsary)
I ( typc�" m, )
00erithemial(Heating/CoolingRaturn) 00ther(explain under#21 Remarks) FROM TO ])FSCFJMON rotor,Hardness,smy-rk n zb etc.
ft ft.
4.Date Well(s)Completed: 'Well ID#AAo-s? Q ft- I /,9L5-1L 111,e� &&r/ AP 110'5p-1
-9)k A 5a.Well Location: Phone # -_ Xcig-21K J% a
fL
ft. ft
L
-Unriev, -ArAn%,_1A 0 r\ "11
Facafty/Ovmer'Namc If Facility M#(if applicable) ft fL
ft. fL
2-3y 7f It
Physical Address,City,and Zip ft ft.
e_ Xi-ele[If 21.REAJAPM
County Paxical Ideiitifioadon No.aM4)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,one laVloagis sufficient) 22.Certification:
2-
6.Is(are)the well(s): 00crinarient or OTemporary ' of
Cted Well Contractor
Date
y iprl,gthisform,l hereby certryihat the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or nNo 15A NCAC 02C.0100 or 15A JVCAC 02C.0200 17ell Construction Standards and that a copy
If this is a repairfll out brawn well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fan".
23.Site diagram or additional well details-
8.For Geoprobe/DFT 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 I is needed. Indicate TOTAL NUMBER of wells (addSee Over'in Rernarim Box).You may also attach additional pages if necessary.
drilled: . Gy 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 76 P - (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(f&fferent(trample-3@200'and 2@1001
10.Static water level below top of casing: 70 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwaier level is above casing,use 11,1. Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) Bit off.- 1003 24b.For InjectionW. eUS: Copy to DWI;,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC27699-1636
12.Well construction method* AIR ROTARY 24c.For Water Supply and Open I-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to JDWR_CCPCUA J-
13a.Yield(gpm) /0 Method of test: Ar R-4qf Permit Program,1611 MSC,Raleigh,NC 27699-1611 sy
J
13b.Disinfection type: 70%HTH Amount: �Lo 3 0z DATE SITE VISITED: V4 V4
Pri rp-: VISITED BY: