GW1-2022-08921_Well Construction - GW1_20220912

7 ;4*,(ELL
nCoNS 1TR1UCTION RECORD GW-1 For Internal Use Only:
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1.Well Contractor Infornintion: ;
;� r l i Gn Calve, K WATEit 2ANES
WeDContactorName
FROM To DESCRIPTION
ft ft. j
y��� ft i
NC Well ContractorCcrtifieatimaNumber 15.OUTER CASING•formulfi-rased wells ORLWFR Hcable
YADI(IN WELL COMPANY,INC. - FROM To DIAMETER M310ECNESSder MATERIAL
ft I f P in.
Company Name � � ai rl 16.INNER CASIlVG OR TUBING !eothermal dosed-loo
2.Well Construction Permit#: l/Oy FROM TO DI&M TER I T33aC ss 1 MATEsui,
List all applicable well construction permits(i.r-UIC County,Slate,Variance,etc) �. 1 ft• 4L-t ft s 1 in. lb A x t 1 #0 V./'
3.Well Use(check well use): ft• ft. m. c�
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THIC7aMS5 I MATERIAL
❑Agricultural ICIpaUPublic ft. ft.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft, ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
01cri ation ❑Wells>100,000 GPD FROM TO,` MATERIAL EEM+PLACEMINTMETHOD&AMOUNT
Non-Water Supply Well: V ft. ft. to/o,%
❑Monitoring ~� "°'� C. very K ft aq ft.
Injection Well: n i V ft, ft
❑Aquifer Recharge 1 J 202FGroundwster Remediation
CC``Dp i 19.SAND/GRAVEL PACK Of a linable)
❑Aquifer Storage and Raei�ely ❑Salinity Barrier FROM TO MATERIAL, ENEPIACEMENTMETHOD
❑Aquifer Test � SC•,?,�5�5o'l�SaterDrainage ft. ft
p gy �&'J'rk4(�.•t3`
❑ erime�a]Te�Bfolo .: ❑Subsidence Control ft
❑Geothermal(Closed Loop) ❑Tracer 20,DRILLING LOG attach additional sheetsifnecessa
❑Geothermal(Heating/CoolingReh ) ❑other(explain under Remarks) FROM To DESCRIMOx rotor,hardness,sosvro� in she etc.)
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4.Date wells)Completed:?1-d` Well ID# _ C ' S ft �Z-
.5a we1ll.ocation: Phone #?36•V 7-Oa93 &
`DS�1�o1�Jrtno�.a �ywis W 3C-057-0 61 .4 ft �5 soFL plw �. -I&^, el
Facility/Owner.Namee Timm lD#(lf applicable) 2 ft Q rdl s o FL' a i
' Lad r, H4LV Lq. �'►�i�z s 70 ft.
PhysiodAddcess,Cft ,and Zip 4.7 Eft 3� t-
21.REMARKS •► /li►• loA/
or
County; Parcel Identification No.(PIN)
--ed 757 119PP
. i I - PSI!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (�
(ifwell field,one lat/longis sufficient) 22.Certification:
N 13Z3U° W
6.Is(are)the wcU(s): rmanent or ❑Temporary Signature of Certified Well Contractor Date
�`J1 By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 0 15ANCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fd/out known well construction information an erp/ain the nature of the ofth/s record has been provided to the well owner.
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 info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'III Remarks Box).'You may also attach additional pages if necessary.
drilled: t 24.SUBIVH TAL INSTRUCTIONS
9.Total well depth below land surface: / ®� (ft) Submit this GW-1 within 30 d ys of well completion per the following:
For multiple wells list all depths tfdjfferent(example-3@200'and 2@1001
?Aa. For All Wells: Original ;foim to Division of Water Resources (DWR),
10.Staticwater level below top of casing: (ft) Information Processing Unit,16 l7 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use"+'� -ram
e Bit Off''-' • O 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in•) Program,1636 MSC,Raleigh,AIR ROTARY NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(it.auger,rotary,cable,direct push,dr..) county environmental health department of the county where installed
s
C FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA �
o 1` Permit Program,1611 MSC,Raleigh,NC 27699-1611
s(M2 13a.Yield(gpm) Method of test: �J f r1 ^
type: 70%HTH Amount: OZ IU.#• .13ti:rDisinlection DATE SITE VISITED: f d /-�
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��®a VISITED BY: l r y te Pr,eta a
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