GW1-2022-08858_Well Construction - GW1_20220912

WELL.-d?+IITSTRUCTION RECORD(GIN-i1) For Internal Use Only:
16.•'�� �'r 4 k
1.Well Contractor Informati
ks G , 14.WATER ZONES
Well Contractor Name —mom
FROM TO DESCRIPTION
/ 9 s ft. g fr. G ON
Iq
S ft-
NC ! G
Well Contractor Certification Number IS.OUTER CASING for multi-task d wells ORLINFR d ap liable
YADION WELL COMPANY,INC. mom To DIAMET$R TffiCKNEsS MATERIAL
Company Name 336-510-k3 zr t� ft ft. CO'S` in- sOR 1 t u L
t9 y 0 L 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: rp R- k/L -2- 0d 2®A/Sy EOM TO DIAMETER TffiCIINEss ATATRRIAL
List all applicable well construction permits(ae.I71C,County,State,parlance,etc) M ft
3.Well Use(checkwell use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMr[M SLOT SUE TrDOMSS MATERIAL
OAgicultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ,residential Water Supply(single)
fr. ft,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
OIrrigation " ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. a�- ft.
❑Monitoring ❑Recovery fL ft
Injection Well:
infer Recharge ft ft.❑A q ' urge ❑Groundwater Remediation
R M FROM TO A
❑Aquifer Storage and Recovery ❑Salty Barrier F 5A1�ID/GRAVEL PACK MA liable
RTERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Ston-nwi ter Drainage ft it
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 20.DRII,LING LOG attach additional sheets if necessary)
FROM t. TO DESCRIPTION(color.hnrdaess:oiUrorJc c,
❑Geothermal(Heating/CoolingRChnn) ❑Other(explain under#21 Rema$ ft.GS) sirs cte
��. Lo 5..�
4.Date PVeD(s)Completed:1AI Well m# 4 O R' 7 7, fL
Sa.Well Location: Phone # �(�,.91.3-49lq �,' �3 ft � •�' �"�-
Pit i—�s-6� 3 ft a�a. fL
Facility/Owner Name F=1ityM#C1rWlicable) ft - ft
ft fL
Physical Address,City,and Zip ft
21.REh2ARKS !
S_P 1 2 _
County Parcel Identification No.(PUD
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees IniC;'^::i=n ?i ?s<« Una
(ifwell field,one Iat/longis sufficient) Certificati n' `I t 1
6.Is(are)the well(s): Permanent or ❑Temporary p/�,,,
Sign Certified Well Contractor Date
p�p�� l ingthisfonn,Iherebyttrtify that the well(s)was(were)consbvciedin accordance with
7.Is this a repair to an eadsting well: ❑Yes or 1 i� SA NCAC 02C.0100 or 15A NCAC 02C.0200 Will Construction Standards and that a copy
If this Era repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner. oS
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infb
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. 4
drilled:, C 24.SUBN TOTAL INSTRUCTIONS
9.Total well depth below land surface: O►�+"IC101- (ft.)
For multiple wells list all depths lfdrffemnt(knomp►e-3QI00'and 2@1001 Submit this GW-1 within 30 days'of,well completion per the following:
T ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water-ve casing,
below top of casing: ft. Information Processor Unit,1617 MSC,Raleigh,If water level is above easing,use"+" g NC 27699-1617
i
leborehole diameter: (in.) Blt Off: 6.0 7fr 24b.For Rklection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.
(it.auger,rotary,cable,direct push,etc)Well construction method: AIR ROTARY 24e.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
county environmental health deparCnent of the county where installed
FOR WATER SUPPLY WELL iS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: i N g+
13b.Disinfection type: 70%HTH Amount. OZ DATE SITE VISITED: X 2L.''g�Z, PZn m y
Pri CP 7 VISITED BY: D MOP