GW1-2022-08632_Well Construction - GW1_20220513

--W-'$.,CONSTRUCTION RE CORD L�GW-1� �F,or;Intemal`Use Only:
1.Well Contractor Informstion:
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Well Contractor Name ' 7Q + t FR0M STo= *D>;SGnIPTION
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NC Well Contractor certification Number ; In15,:0UTERrCASI$GI for"mniti,�sediveDs(URtiL11HER?rfa licefile
YADKItJ WELL COMPANY,INC. rxoM bTo: !tnrAnnaTSRlrI>kTffic�rEsslr IiMAT1CRIkL
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Company Name.
t rtti*16$IN1VERiCASIlVGUBFTUBING, 09M,closed loo
2.Well CodstrucNon Permit#: �✓�if1%4/3/. -�2o.L( " + oM &ToM JIDLOARTERMINTMCKMslr iEracTat:ui.�� (�
List all applicable well construction permits III.a.UIC,County,State Yarfance etc) =10111 ft SUMS"3.Well Use(checkWell use):
Water Supply Well: ; `� '1617.ISCREEN
.. b, amtUMl�STOt ODLVNZ tdIr1 1SI:UTsSms l<TS[CiQVSS51!)tYlATERIi1L�
❑Agricultural ❑MumcipaUPubltc`:.
❑Geothermal(Heating/CoolingSupply) identtal�. F.SuppI (single) ft. ft. to
❑Industrial/Commercial bRrstdenfial Weter'Supply(shared) I filB(GItUUT
❑Irrigation ,❑Wells>100 000 GPD �pRo >,sTo>rltar iMATF +Irrl>?L*n�r/nCior»T+METaoD►�rAMomrr�
Non-Water Supply Well: .
❑Monitoring ORewVery If it i0� ii;Atil ��lriV
Injection Well;
❑Aquifer Recharge 1[7Groundwater Remediation
1191SA1!IDIGWAVELiPACKIifa llc`able
❑Aquifer Storage and Recovery OSalimiy Barrier WROM VTo1 iMkrERL►L tLP11�I kGE11ttENT.MLrrSOD1�
❑Aquifer Test OStormwater Drainage
'1 ft fl
❑Experimental Technology sp�.� [7Subsidcnce Control
❑Geothe[mal eattn COOlm Rehun []Tracer 112U3J?RII;I IG;L'OGi a'tfnrhfadd 8onel ONI if nee`esea
❑Geothermal(Closed Loop)
.�, )FROM t}TU1��DFSCR7pTtON:c'oloclharda'
(H g/ g ) l7Otheri(explaia�underl#21 Rrmyatics) ��tt� SD.
4.Date Well(s)Completed a .Well+ID# Q 'BT��t �
Sa.Well Location: 1 lip
ttr'Pr1011@#i3F. -- O$t/
y x Qt� s �!1Gt b /�tQ 40i�Q IVga ft ft
Facility/OwnerName l �4 Facilityim( so
ifeable) -
x
+sc t } �" ft ' +
`g3 o
oar Adder cry.�a t ft
,�, ,. , �t L, iFi1�R
Co tyr a Frei l tt56sa0n No.(PTDi)
5b.Latitude and longitude in dt'grees/tntntes/seconds or,decimal'degrees:
tfwaU fiel one lat/lo is suffierent r * ?""
(' d, ng
Z3. Rl _"NUR
--
` { Sign - f «IWeliGoatractor Date
6.Is(are)thewell(s)c Permanent or ❑Temporary
1� s;
.��� Byslgn,�g�hlsfatm,I'herebYcerf�p atthe:well(sJ as- ere�catsfivcted•lnecco ce
7.Is this a re air to an eidsti well []Yes or; .,J 'ToOIC.DI.00 or 15.4�NCi1C 01C.02001Ye11 Construdian SYmrdm dr anddhat.a ropy
P 17 6 ram' this-rerordhas been ovtded to th wail owner
Ijihis.fs a spair,fdl out known well canstruchan injormatian d e:plom the nature of the °j
repair under#21 remarks section or on the back cjthis form r Y. 23.Site diagram or additional well details:
8va
8.For Geoprobe/DPT or Closed-Loop Geothermal W"ells lrevmg the smme You may use the back of this page to proxide additional well ccroshv 'on info
(add See Over'in Rcmedcs Bar). ou may also additional ages ery.
construction,only I GV$-1 is needed Indicate TOTALNUMBER•of wells
dii7led: ( ��` 24.SUSMTCTAL INSTRUCTIONS
9.Total well depth below land surface: - ( ) Submit this GW.-1 within 30.days of well comp etion per the folio
For multiple wells list all depths!fzVerent(erdmple 3(n)Z00 and 2®100J
Isla. For All Wells: Origittel form to Divisirm of stet esourees (D ),
_.10."Static water level below top of casing: ® 4» luTifTwormaU011W
ProingUnit,1617 MSC,Ralergh,NC 27699-16 7
Yljwater level is above casing,'use
r, G $t •�,, 0 24b.For Irtiection Wells: Copy to DWR,Underground Injection Gan r
11.BorehoIe diameter: (m) r Progtmm,I636+11�ISC,Rkiigb,W-27699-1636 (�
- AIR ROTARY '` *_ ""`
12 Well conshvction method: C.For Water,SupDly and Open-Loop Geotherm 1 Re rn 'ells.
(Le.anger,rotary,sable,direct push,eta.) ppuiity enviromnental�healthvdeperhne'nt of the County wheieliiistalled
FOR WATER SUPPLY WELLS ONLY: r 24d.F.or WaterWells produ ' t3 oxer 10D,000 GPD;Copy bo DWR,G CU
13a.Yield(gpm) o I �.�r� 4Permit?Piogiamu,1611 MSC,Releigh;lNCi27699=+161►1
3 Method oftest: /rrwl
70%HTH �0' ' O2" t DATE SITE VISIT ED:
13b,Dt.infection type: Amount: .
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"cV151TED BY: