GW1-2022-09493_Well Construction - GW1_20221014

NVE I. 'q—ONSTRUCTION RECORD(Gov-l) For Internal Use Only:
�j coonnttracto)r 1, ormn600:
1.
"/� -ri''f�1A.J . An wn LA.WATER ZONES
PROM 1 TO F DaaCRIMON
Well Conuaetor Name 3V R
3o3 R R
U
NC Well Cooliaetor CedrScati—Number PlLnMCM
TER CASQ'Gformd6-cased weft OALWER dapplicable)
YADION WELL COMPANY,INC. ro D1AMiTIIt TM TsruAt
�r/ R
Ca®pmYNama I -� 3..1/—fiT 7Slo vJ
('+1 4.(e tq (:ASR•iG OH TUNING thermal rimed-too
2.Well Construction Permit#: 6 3 S TO DIAMETER TsOuss MA7ffiOAL
Lhfoilapplicable wall construction penvor(La.ABC County,Sim,Yarlarim,ere) RR / is- _ L/3.Well UM(cbmkwell use): R fR in. l�REEN
Watrr Supply Well: FROM. I TO 1AataT'l:RI SLOT 3= I THICInW KXTaiWL
C Agticuhmal OMrmicipal/Public
DOeoibermal(Heating/Cooling Supply) AlKidential Water Supply(single) tt Ia.
Oladustrial/Commemial OResidential Water Supply(shared) 1B.GROUT
Alai 'on OWells>100,000 GPD FROM 1 To MATERIALEMt CEMENT METHOD A AMOUNT
Nan-Water Supply Well: ft' ft 'f GrGvi y.2
OMoriitnring OMecovery R R
Injection Well: R fL
OAquifer Recharge OGroundwater Remedistioa
19.t1AND1GRAYEL P de hie
ClAquifer Storage and Recovery OSahaity,Barrier FROM To MA CKMENT METHOD
OAquifer Test OSimmwatc Drainage R R
OFxperimeatal Technology OSubsidence Contra! R
❑Geothermal(Closed Loop) OTracar 20.DRII.L71rTGLOG launch additional sheets if nerass
OGeotLemlal eating(Cooling Rehan) 00dw(explam,under#21 Ramada) FRr1M To nsacatPnoN color haNnm mahark eR
FfL
R �o. •�
4.Date Wells)Completed: q'Z -2 Z ell mn 80 R J
rIL A0 IL 144.4
Ss.Well Loeatioa:�v/S(.i(64 hone # _� R
lFe�l1 n 48Y Ssxt
Fse"titylOwnerNaim ID9@falTlieald ft.
c&r Cad mod, Lei n� E I kt r R
phlyo l Addee, City.and Zip R -
2022
2L REMARKS
W0, lI ft'
CDU* pmeei identi6mtionNa(PIIi)
5b.Latitude and longitude in degreea/minutes/seconds or decimal degrees:
(if wall field,one lat/loagis soff dent) 22.CertMERtian:
3G.` / /5,* -N R . 5 V 25.o y<„ R -23-2 Z
6.ia(are)the we0(s): 9Permanent or OTemporary OSifoature ofCrrUcd Well Cmhactar Due
By sip brgthirjarm,I hereby cer*that the well(r)was(were)cmatructedin a=r&mce with
7.is this a repair to an eating well: Oyes or @go ISANCW 02C.0100 or/5A NCAC 02C.0200 Well Consbudion Standardr and thai a ropy
Ijthtr tr a repair,fdl m,brown well construction br,famratfan mid erolam the naeae of the ofthis mwrdhas been proulded to tha well owner.
,quirmrder 121 remarks section or an the backajthlsjorm.
23.Site diagram or additional well details:
8-For GeoprobdDFT or Closed-Loop Geothermal Wells having the same You may use the be&of this page to provide additional well construction info
constructions only 1 GW-1 is needed. Indicate TOTALNUMBER of wells (add'See Over'inRemmis Box).You may also attach eddmonal pages if necessary.
drMcd: + X SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface: 0% 0 (ft)
For multiple wells Ila all depths ijdif(ermt(emmple-3@200'and2®1001 Submit this GW-1 within 30 days of well completion per the following: �.
10.Static water level below top of easing: 6 O (R) 2J4a. For All Wells: Original form to Division of Water Resources (DWR), L
ywcler level Is above rasing,we'•+• Information FroeessingUnit,1617 MSC,Raleigh,NC 27699-1617 s
11.Borehole diameter: (ia,) Bit Off' 4,o84 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) '
Prograrn,1636 MSC,Releigb•NC 27699-1636 ti
17.Well construction method: AIR ROTARY (•
(is.auger,rotary,cable,direst pmh,ern.) - cm For Water Su 1 sad de en-Loop Geothermal county Return c mulcWella:Copy to the 1
county mvhonmeatal health depmfineat of the county where iaa eel
p
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingover 100,000 GPD: Copy m DWR,CCPCUA "A
(gP ) (�— FM= gram,1611 MSC,Raleigh,NC 27 -1 11 'As
13a.Yield m Method of test: /`l� 2rr �
0
13h Disinfection type: 70/HTH � Amount: o`( 6 oz DATE SITE VISITED:.
aAdrta.."`- iw.6'sTu VISITED BY:
. . . `r'..:---.—_.,—.�. a_. . !vyvssmmtal Quality Division of Water Remare.n a..,..d6 7mx