GW1-2022-09485_Well Construction - GW1_20221014

MMILL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well CCContmcNr information:
1 (a- 41,10y 2 LJ"n WI1 14.WATER ZOrIES
Well Cnntnetor Name FROM TO DL4MMON
3036A 9( R Z ft Va.NC Well Contractor Cedif-Hoo,Nmtbw A 4 IL T 2ro 11.4 2 %s
IS.OUTER CASWG ormvla-u¢dwells OR LINER Ifs liable
YADION WELL COMPANY,INC. HROM DUMCIER THICENEss I MATERUL .�
R n
Company Name
34 t 7 ff BUM CASING TUBING thermal closed-loop
2.Well Construction Permit#: ` PROM •m Dwm� Tfficmiscs auT�tk1.
Liss all appl/mb/e well construction pnmfls(ee LUC.Comfy,State,Yar emm etc) f- IL ( in. -WAe-7 plde.
3.Will Use(check wall use): R R
Water Supply Well: 17.SCREEN
FROM 70 DIAMELEts SLEYr S E THIOOYFaa MATERIAL
ClAgricultural OMunicipal/Public R. is
OGeuthermal(Heating/Cooling Supply) Poesidential Water Supply(single) R.
t]ladusoiaUCommeroia] OResidential Water Supply(shared) UL GROUT
0brigimcm 13Wclis>100,000 GPD PROM m MATEn1AL EaffLACEM&rl'MEIRDD@AMOURT
Nou-Water Supply Wall: R. �3 R 7(.44L GAS
OMwADring DRecoveay R R
Injection Weil: R R
Aquifer Recharge OGroundwater Remcdiation
19.SAND/GRAVEL.PACRda liable
17AQIIIfEr Storage and Recovery �Sa1lIllty Bamer FROM I TO I MAIMUL I EMe5CEN2NTMErg0D
OAquit r Test OStormwater Dramage R ft
0EVermzmtal Technology OSubsidence Coabol R ft.
OGeothenal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets line,-
OGeothermal(Hcatmg/Coolmg;Beoaa) OOther(Whin under#21 Remads) 'mom To I DEsrgBuoN amr huanea..wf sea rim err.
9• l9- 2L mtr 4� $3R f fL ��.. R b/ `1 n6
4.Date Well(s)Completed: Weu
sa wauLeeanDn:�sa Phone # 3G-- 3-��3/ J R 'L S 1�
CAL-( / W✓/weh 90 , J63 R &A.;Ve
Famlity/Owner Name R
,✓,, Pad/itylII)#(depplio/eble) R•
Physical Address,City,and zip ft. fL UL I 1 6 2022
A-S/Lss C, 2L REMAKES
Comfy Parcel Ideatifinpoa No.(PIN) Ieeve C
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - e�
(ifvml]field,me ladlongis sufficient) 22 Certific 'on:
3 lfi l4 'S'o/ N $ l YO G, �'f a !/!A
6.Is(are)the well(s): Permanent or OTemporary Sngoamre of C¢hfied Well Coanacmr Date
By signing thisform,Ihaeby cerfffy that the well(s)was(were)emsnvded in aceurdom,with
7.Is this a repair to an existing well: OYes or I`�V0 15ANCAC 01C.0100 err ISA NCAC 02C.0100 Well Construcf[m Sf dords and that a ropy
TJihis lr a>rpol%f(fl out known well conshuclian btformatfan�jd e�zploin the nature offhe affhls recordhas been provided to the well owner.
repair mderfll remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For Geaprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well cousouction mfD
construction,only 1 GW-�is needed. Indicato TOTALNUMSBR of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary.
�cd 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V?6 3 (ft.)
For multiple wells list all depths Ifdifjemnt(ermop/e-3@200'md1Q1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below tap of casing: (tL) 24a. For Ail Wells: Original form to Division of Water Resources (DWR),
lfwow level is above casing use"+" Inf , ation PmcewdngUnit,1617 MSC,Raleigh,NC 27699-1617
i
11.]Borehole diameter: 6 (m,) 13tt off:. yq , 24b.For Injection Walla: Copy to DVI&Underground injection Contra] (TUC)
Program 1636 MSC,Rsleigh,NC 27699-1636
12.Well construct AIR ROTARY method: � M� n�Y 24c.For Water Supply and Oven-Loop Geothermal Return Waits:Copy to the
(i.a auger,many,mblo,direst push,etc.) county eDnroumental health department of the county whom installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Willa ondodn over 10,000 GPD: Co to D
Permit Program,1611 MSC,italeigfi,NU 27 -1611 Copy
'CCPCUA
13a.Yield(gpm) _ Method oftest•_f4140 / _
136.Disinfection type: 70%FIT}i Amount: 02 DATE SITE VISITED: /�—Y
Ayeo CAF14J FjsFe•.
VISITED BY: //I/