GW1-2022-08477_Well Construction - GW1_20220408

WELL CONSTRUCTION RECORD(:GW-1) For Internal Use Only:
1.Well Contractor Information
/:
Q I Alen, cLJ/�w✓1 14.'YVATER ZONES
Well Contractor Name FROM TO DESCRIPTION
311 ft 3.s6 3
NC Wen Contractor Certification Number 15.OUTER CASING for lulti-ra ed wells OR LIMIER rf a licable
YADI4N WELL COMPANY,INC. FROM TO DIAMETER I 333teRMSS MATERIAL
ft.
CompaayN®e ,y 16.ROM CASING OR TUBING thermal closed-too
2.Well Construction Permit#. Y-al M/-- 01 S 9 5-1-1 -�V•� EOM To DIAMETER I THICOMS MATERIAL
List all applicable well construction parm_its(ae.UIC,County,State,Variance,etc) ft ft c in
3.Well Use(check well use): ft ft, in
Water Supply Well:
17.SCREEN
FROM TO DIAMETER SLOT SIZE THIGlOYE55 MATERIAL v
❑Agricultural ❑Municipai/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) t ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD mom I TO MATERW. EMPLACEMMTMETHOD&AMOANT
Non-Water Supply Well: Q it.
❑Monitoring ❑Recovery 3 ft 02 4Z
ft.
Iniection Well:
ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK sf applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM To MATERIAL IACEWNTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft: fL
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remadm) FROM
TO DESCRIPTION color,hordnrs:,goiYrocktypr,graiu sfre,etc
B ft ft
4.Date Well(s)Completed)-d�Well IN �' �p ft. TZ1 IL j or4 A*,"
r
5a.Well Location: Phone # -Aj�- 510 4 7 t Y ft ft.
ft. fL
Facility/Owner ame ���( Facility M#(if applicabl�e)f�J fL f L P PR O 2022
.O/CA: L.sr�J G/u C//tMlQt ft. ft
Physical Address,City,and Zip ft ft. a• l: 1 +t
ya �C
//_[eh 2L REMARKS
County (� Parcel Identification No.(PQT)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3l N Sd '414 S o,x W
6.Is(are)the well(s): Permanent or ❑Temporary Sfnatnre of Certified Well Contractor Date
By signing thisfom,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or10 15ANCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,Jill au known well construction information and erp/ain the nature of the afihis record has been provided to the well owner
repair under f21 remarkr section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobc./DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info Q
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'uI Remado Box).You may also attach additional pages ifnecessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths If diferent(example-3(a)200'and 2©1001
10.Static water lout)below top of easing: ® 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing UA 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
MOM 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 4C (in.) Program,1636MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24c.For Water Supply and Open-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 DWR,CCPCUA .
13a.Yield(gpm) 41 Method of test:
Permit Prograrn,1611 MSC,Raleigh',NC 27699-1611
�q/ l/•
13b.Disinfection type: 70%HTH Amount: oC OZ DATE SITE VISITED:
Pri ---------------- VISITED BY;