GW1-2022-08835_Well Construction - GW1_20220912

a� QN -UUCTIONRFC R3DfOW-1) For Internal Use Only:
1.Well Contractor information:
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C�pt&ac, J tdowG , W . 14. 1tR 'to
WellCunlsaGorName VROM TO
-1 �M DBSCaBLON
i So R R 6h^-
NC Wen Connector CatisaatmNmober '�O R /7 R y G�
15.OUTRR CASAIG torrnnlaosed webs ORLD� da livable
YADION WELL COMPANY,INC. FROM To DTAafL7RR Tffit8lMas MAT AL
Company Name ' R ✓ 4• 7 S � SD -a f V
16.IFn•�R CARING OR TUBING thermal cloeed400
2.Well Construction Permit#:INS(AP - 013'3/r- 2a 2Z FROM To mOuilor R TKICT0• S MATEBW.
Lid a0 applicable well construction persclis A&rBC Caw*.Ma A Yarlonct d a) R R ia.
3.Well Use(check well use): R R in.
Water Supply Well: 17.�1
FROM TO DIANI'M SLOTb'1Za THIC011101 MATBRIAL
❑Agriculbual ❑}ry�lmpal/Public R, 8, in.
oGeothecmal(Heating/Cooling supply) Zd'eotiel Water Supply(single) R ft. - in.
OladustrialiCommercial ❑Residual Water Supply(shared) IL GROUT
Iffingatim ❑Wells>10Q000 GPD FROM TO I MATERIAL I RMPLACWdHITMZTHOD&AMOUNT
Non-WaterSupplyweli: ft. q& ft. A� s •te e
OMorortatag ❑Recovery R R Injection Well: R R
CAqufer Recharge OGmhmdwdter Remediatiw G
39.SAFOIIGHAYRL PACK Ito cable)e `
OAtphifra Storage and Recovery OSatinity Barrier FROM TO MATIIUAL I FJdF1ACZ1s3=?A 0D J�
❑Aquifer Test ❑Stormwater Drainage R R
OExperimentel Technology ❑Subsidence Control fe. R
❑Geothermal(Closed Loop) OTracer 2a.7/RR*TMGLOG fittlach addih'ond sheets if necessary)
Geothermal(Hestiog/CDolmg Behan) 00dw(explain under#21 Remadta) FROM I Tn IDxsr�aox color huuaam,manaet es.
4.Date Well(s)Completed:F-2-V-21Z Well U1N � Or B. SO ft[ IC/� iSae( Qgtf r )
5s.Well Location: tt G ft a /S G.•.../* 4. s A-4a-,
L/ Phone fi69- z�sg
n Ailift) Aaasey, Oft R roF R ",r Is sl I a
Family/OwnerN®e ?am 7HyBN Cif w1bable) 102
R D
IY X W 0 ►t S leas kley yd (e- R R _ I:t:-r
Physical Addm4(sty,and Zip R R
Ye, d kt F. 23LRMKARIO
County Parcel Idenclicatica ND.0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field,una latdoagis sufficient) 22.CertiBcati ; /
36L J 032.tSN &) 35 �rrut� W
6.Is(are)thewell(s): t7Permanent or OTemporary ofCetiSed Will Cmmecmr Dare
BYslgn/ng thlrfonu,Ihereby cer*ihat the we11(r)we(were)censor d in acaordmrce with
7.Is this a repair to sn existing well: OYes or o lad NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
Ifthis is a repair,fRi our]moan well covstmadon b,formation and arploin the nature ofthe ofthis record has bsm provided to the well ownee
rrpw under 421 ramarkr ieGlGn or on the backgrohiaform.
23.Site diagram or additional well details:
L For Geoprube/DPT or Closed-Loop Geothermal Wells having the seine You may use the beck of this page to provide additional well construction info
cor shuctitm,only 1()W�is needed. Indicate TOTAL NUMBER of wells (u'See Over'inRcma dcs Box).You may also attach additional pages if necessary,
wed' 24.SUBMITTAL INSTRUCrfONS
9.Total well depth below land surface: (fL) Submit this GW-1 within 30 de of well completion par the following:
For multiple wells lift all depths Ifd�erent(emmplo-3Q200'ond2®100) 1'a P P
10.Static water level below top of casing:_ 3 S (D-) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwcter laud is above caring can••+" / I-f mnatian PmceL%higUhhit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: G (in,) Bit Off: v rdS 3 74b.Far Injection Walla: Copy to DWR,Underground Injection Contrail(IUC) C)
Pmgnem,1636 MSC,Raleigh,NC 27699-1636
12.Well conatruction method:
AIR ROTARY 24e For Water Supply and Open-Loon Geothermal Return Wells:Copy to the Q
(.e.roger.rotary.cable,died posh,eta.) =1115 envm mental health department of the aimity whore installed
FOR WATER SUPPLY WENS ONLY: 24d.For Water W ells rpdacin over l00 000 GPD: Copy to DWR.CCPCUA q
13a.Yield(gpm) `"'O Method of test:4s^ P�td gram,toil C, agh,NC 21 99-I 11 4
13b.Disinfection type: 70%HTH Amount: 02 DATE SITE VISITED: '7- -7 - 7-2
Pri r•P- /is (Ir T F 7.a a VISITED BY: 13 J23 �•5