GW1-2022-09484_Well Construction - GW1_20221014

mm �coNstrguc CZoNREC0RD(GW-1) Forlintamal Use Only:
1.Well Contractor information:
l[1��/f 1 /fie
// lA ZOM
,dell Cantonal.,Name FIIOM TO D180aFpols
_ 3034 .4 oR4b0R
R R
NO Well r....«"tw Cedifica4rmNimhc
15,OVPEHCAga'IC*forniniti-cased wells ORLBVER da Grahle
YADIQN WELL COMPANY,INC. FAOM TO pUMaT$R assess burs
R
Compa°yNma
OHTIIRA'G eodiesmal closed-too
2.Well construction Permit (i ><laoIs TO maab'raa amctrness a+A'i'>�Ai.
Llrl all applicable wall eonsinctlon permits(ce.BI1C,County,Slate,Parlance.etc.) V�,
3.Well Use(checkwell use):
Water Su Well: 17.SCREEN
PPtI' FROM TO D Sim a= TDILTam MATFFI,tL
DAgricultarel DMunicipaWablic
OOeothem-W(Heating/Cooling Supply) Afkesidential Water Supply(single) R, In. �.
"OladusaiaVComrnemial DResidentiel Water Supply(shared) la:GROUT _VV
Qlrri 'on OWells>1000000PD FROM To MATmsrAL M0LACMsSNTMT ,tt AInd K
Non--Water Supply Well: - O ff' oZ SM. ES.a.a�ia/{e. /.z
OMomtoring ORecovery R R
Infeciou Well: R R
❑Aquifer Recharge DOrmmdwalcr Remedtehan 19.SAND&RAVEL PACK rs llrabk
DAgmfrt Storage and Recovery OSeImityBarrier mtOM To ' MA eMrtwcastmtxtdMOD
OAquft Test OSmrmwater Drainage j
R
�ry�artel Technology OSubsidance CmdnA 00coth®al(Closed Loup) OTracer Gatlaeh additional sheets ifnerean
.Opeotheemal etipg/Coolingl3tAnp) OOther*plain soda#21 Remeds nrseaffaa comr hudvea.oivraea , efe
� it
4.Date=Wells)Completed: �D- z-Z WellID#I!—r r� D R a5s.WeuLaeatian: Phone # 70y^-So2,) R l R
(rd L..reti
Famlity/OwnaNeme PeoTitYIDN Cdeppliaehla) $ R
Abe Acxl 73 ew
Phpiaet Address,City,end Zip
---sk''d L s{,J
Cmmty - Parcel Bdeatifioati®No.0mg)
b.Latitude and lougitudela degrees/minutes/seconds or decimal degrees:
(ifwa0 field,ono Wllhngie suSmie°t) 22.Certification:
N 8r 90 !;-Lp AG /0--5 2t,
6.ls(are)theweR(s):Permanent or DTemporary Siiggaalore of Certified Well Cnabsemr Dam
Bysignbtg thisfmm,Ihemby cerlry that the wells)was(ware)cro strudedin accord motWith
7.L thin a repair to an existing well: OYes or ONO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construarm Stmrdards and that a capy
)Ythis is a npao-fdl one brawn well ,,,slrucfion aiformation and explain the nsaure ofthe ofihis record has beeproldedto the veil owner.
rep°Irtmder{21 remarkr section or an the back ofthis form. 23.Site diagram or additional well details:
S.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
coushudion,only 1 OW-1 is needed Indicate TOTALNUMBBR of wells (add'Sm Over'in Remarks Box).You may also attach additional pages if necessMy.
drilled: rA
9 Z 24.gMED[ L INSTRUCTIONS
9.Total well depth below load surface: Sd A) Submit thin GW-1 within 30 days of well completion per the following:
pormulflpia wails Ust all depths If dgleratt(el.pie-3©200'and2@1001
�J) 24s. For All Wells: Original form to Division of Wafer Resources (DWR),
10.Sla4ewater level below top of easing: (ft) Information Processing Unit 1617 MSC,Raleigh,NC 27699.1617
ywu&r level is abase casing sue"+" i 081Y
11.Borehole d imeter: G (la.) Bit�'-�� 24h.For Injection Wells: Copy to DWR,Underground Inf nation Control(RUC)
Pmgrem,161636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
AIR ROTARY 24e.For Water SugplRand Open-Loop Geothermal Return Wells;Copy to the
anger,roh mb,ry,cable,directp do.) county epvimnmeotal health deparimept or the county where installed
d
.. FOR WATF,R6UPPLY WFSSS ONLY: 24d.For Water Welke producluE over 100 000 OE
Copy in DWR,CCPCUA r�
' � ) Permit Pmgmm,l 11 MSC,Reletg ,NC 27699-16 1 V�
13a.Yield(gpm) 1j. Method oftest: jl V /
3` DATE SITE VISITED: b '.Z 2 2 Z
136.Disinfection type: 7D%Fff}i Amount: _ OZ