GW1-2022-08546_Well Construction - GW1_20220513

�e0NSTRUCT1 10N RECORD(GW-1) For Internal Use,Only � � 41V
1.Well Contractor lnfornation:
w �t7�1//p w10WATER ZONES � + �� :, ir►
Well Contractor Name
FROM �,E�T'O :as DtiSCRIPTIAN
303(a'A/�
ft. it
NC Well Contractor Certification Number Ark° -p.•- !W-e �.
�c15.(UUTER?CASING:for,mu]&:eesedardl3 TOR�L'Il!iERr rfa
YADMN WELL COMPANY,INC. FROM To kDlAMETER 4THIt�NES3,rMATEarALr�r .
CompanyName Ij j'3- S 2 (y 166II�IIVERCASIIVG;OHiTUBING f0iffrmal?dosed`:loo a�
2.Well Construction Permit#: l SO% ,..i'4FROMS"14TO DDIAMr=MMITMCIOM =lMiiTERIAL�,
List all applicable well construction permits(Le.EUa County,State,YariFq! eta) in. ,OC
ti IL ' m ,
3.Well Use(check well use): t
" N 117 gSG'IMN
Water Snppty Well: a: r 11FROMM ST0r1 1DIkMETER '9SW SUXA`TMCMX5Sti�MATER[AL'r
OAgticuitnral ❑�ljttntctpaUPub11 �.k � ft. 'a
OGeothennal(Heating/Cooling Supply) sideatial Water Supply(single) tt.
OIndush-ial/Commercial OResidential WatterS�upply4(�shared) IBrGROUT
❑h7i On DVJells>l00,0O0'GPD rFROM�!TOY IMATERIAL IEMPI:ACEMENTaMETH0D�rgTAM0DNT7
Non-WaterSupplyWell:
CMonitoting !]Recovery it S
Injection Well:. sf
OAquifer Recharge 110roundwater Remeihahon
� I9�SAPIDIGRAYEL'+PACK da lic`a"lilE
erOAquifSr Storage and Recovery 7Salinit Bv > � 11momam 1MATERUV J1 ff1XCEMLNT:MrS
n UD
OAguifer Test Idi rmwsYer Drainage $ �`
oExperimental Technology []Subsidence Corpnl'
❑Geoihermal(ClosedLoop) 0 MRl;i0bDRILLINGI:U:G'a'tiachTed3itioneltahets�ifnecesa
❑Geothermal(Heating/CoolingBet ro) 00t ' (gitplam;under#21 Retnexks) *FROMi 4701 rDasGR>MOK ml F7 aFdaen roatm—ex""
4.Date Well(s)Completed y' 7� 2ZJ*e11ID#� 'l �-3 /OvTJ I W.9fv
.�
Sa.Well Location: � PFlone
i •A�..a�.- a.
ft ft �
�:m +-a� ft ft
F`amlity/OOwwnc/N�amfe FacilrtyID#0f.apphceble)
owl 011150AIMMEN
° + "T
Physical Address,City,and, t ,.�� ra r
Cody, . TO FaroeliIdratifc"°'atioallo'(PaT) �fl#0fAi8s♦0f1 fO
� BOG
P
5 .Latitude and longitude in degr s/minutes/seconds or decrmal degrees:
(ifwellfield,one Wong is sufficient) ` ���� '�sn 22•Certification:
6.Is(are)the well(s): OPermanent or ClTemporary
5rgaetnre o CerhSedWell dL for Date
Bys/gn�argisform,lhetebyarfjfytha the,well(s),was(were)cmts6uctedtnarxordancewtth
7.Is this a repair to an e3d sting well. Dies or 'L�Ro '� 1SAINGAC 01C D,00 or 'Ad Well Construclfan:Standards and Utot.a co
lfihis fs a repa/r,fdl out known well construction i>fformation and aplam,the nature of thethts neeord:har,beenprovlded fo lhe• ell owner
repair under#21 remarks section or on the back of this form
-• 23.5ite,diagram or additionalw details:
S.For Geoprobe/DPT or G7osed-Loop Geothermal Wells havuig t same You may use the back of this page tO provide additiotrel well constsucRon info
- °. (add Sao Over'in Remarks Box).You may also attach additional pages,' +necessary.
cons�tmction,only 1 GW 1 is needed.Indurate TOTAL NU1VlB13R of wells
dn7led:• 24.SUBMr�rA7.•]OVSTRUCTIONS
9.Total well depth below land surface f4 ^Wf (ft) gU itlithis GW-1 within 30 days of well completloD per the following:
For multiple wells list all depths ifdifferai(trample-3Qa ZOa a�n�2 laq "a-
4 7 .wlata. F.or Ail Wells: Oripnal form to Division of Water p ourc
10.Static water level below top of casing: ><t� (ft') Infomtati"'WrocessingTTnit,1617 MSC,Raleigh,NC 27699-161i7
if water level Is above casing,use"+' 71r/
13it Off 640.F.or Inflection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�•) r Kg� ,1636`-1VISC;4Relpgh,NC 27699-1636
AIR ROTARY y.:
12.Well construction method: :24c.ForlWater;Supply;and;Open-Loop Geothermal.Return Wells:Copyto e
(i.e,auger,rotary,cable;direct posh etc.) x county*environmental ihcalth dipartment of the county Wfieiz!iirstalled
FOR WATER SUPPLY WELLS ONLY
: 24d.For Water Wells producina,over 100,000 GPD_:Copy to DWR,C CUA
7 J• 1 �yPe rout Prognun,+161:1 MSCdRalergh,NCu27699a1'61+1
13a.Yield(gpm) Method oftest (�' 4s >'
70%HTH � OZ� ,,,DATE SITEyV1�31T�ED: ry 22
13b.Disinfection type: Amount (r
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