GW1-2022-09496_Well Construction - GW1_20221014

WEI L C- .S I�RUCTION RECORD(GW-1) For Internal Use Only:
I.Nell C etor Information:
1�on �� urn 14.WATER ZONES —
Well ContmatorName PROM a
;13
DPaCRD'TION
3v3Gff ♦a� o G NC Well Connector CMrti&Adi®Numba< a , a
JA OITM CASING for malti-used wells OR LINER Cdapplicable)
YADION WELL COMPANY,INC. PROM DIAARTER 77KICI NISS MkTSRIAL
R in
C®pmyNsme ] 4Tr- 7 f$O 16.lNl�R CASING OR G the dosed-loop)
toe 1�e/ it- PROM TO mummR T'mcxnn MATSWAL X>
2.Weu ConehTrctloo Permkik � qi� �
Lht all applicable well emutrvatim pvnib(Le. Caarrty,Mate,Yoriance,etc) l R a 'Af in. 1 SP12 f V
3.Well Use(checkwell use): R I ib in. �-
Water Su ly Well: IT.SCRKIN
PP PROM TO DIAM ZR x=s= TMCaNfLSs MATERI,IL
DAgirmltma] OM//imicipeVPublic ft. ft.OGtham eoal(HeadingCoolin Nes g Supply) identia]Water Supply(single) ift. in.
DIU&Lg,;wcommamal DResidential Water Supply(shared) 36 GROIIT
Maigation OWelis>10 000(1PD PRDK I TO I MATEIOAL I WEPfACEM6dTMEMOD&AMOUNT
Non-Water Supply Wdl: 0 ft. a a I
OMad[ormg DRecovery R a
Injection Well: R &
DAquifw Recharge OOmtmdwsDer Remndiation
U.SAND/GBAVEL PACKIfa liable
DAquifv Storage and Recovery OSaltiity Beerier PROM m C¢M¢ MEmoll
DAquifer Test OStmmwater ,Damage a R
DExperitrum el Technology oSubsidence Control a
DGeothermal(Closed loop) O11acer 20.DBIfJ.1NG f.OGsthchaddftionalshmtsifneeess
OGeothamel(Heating/Gboliag Batitm 0O81c 101da#21 Ramada ' I TOI DFSCRIMOx solar bsadom-w-aa a
( o a xr a
4.Date Well(s)Completed: 9'll'2 Wen ID#�VTL7 $ /op R w — S
5%Well Location: Phone#_'M-'? 7-03o a a Ha G
e'LrY1:K�ul a /wao4� R a ""
Fsulity/OwnaNme PaddyllM(dsppliuble) ft. R - ..
2y0 gj)af._ de&AQl a a
PnynadAames%aly,and zip R a Z 121
r� 2L BIA A=
County Famd Id, moon No.(P1N)
5b.Latitude and longitude in degrees/mtnuteslsecoads or decimal degrees:
(ifwe11field,one Ist/longis sufficient) 22.Certification:
19 N Cv WIL (f gy w
6.ls(are)the well(s): a0l"rmanent or OTempDrary Kgr amte ofCadibed Well Contractor Date
BY s/gnbrgthbform,I hereby eer*that the wells)was(ware)constructed in aaordmree with
7.Is this a repair to an existing well: OYes or Cfio ISANCAC 01C.0100 or 15A NCAC 0IC.0200 Well Cmsn dtm Standards and that a ropy
Iffhb Is a repair,flll aw brown well construction brfarmatlarl and asplabr the nature ofthe ofthis record has been provided to the well owner.
rtpair=der#21 ramorkr section or on the bock ofthis farm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the s®e You may use the back of this page to provide additional well construction info
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER of wells ( 'Sa Over'inRamada Box).You may also attach additional pages if necessary.
drilled: --J 24.SURACaTAL IN6171UCIION6
9.Total well depth below land surface: 6s>2 -( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple welb INN all depths/fdj8erent(emmp/a-3@200'm02®1001 -
ti ..A . 6 d 24t. For AB Wells: Original iron to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Proerssingilni[,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above wift,,vse"+" _
11.Borehole diameter: _(In.) Bit Off:,- . 9ef o 2i 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
24L For Water SuDDIv and OOen-Loon Geothermal Return Wells:Copy to the
(i.a sugar.many,oabK dtra mity t pasb,eta) co environmental health department of Ore county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wd11 IDdnciD over 100 000 GPD:Copy m DWR,CCPCUA
13a.Yield �0 Method of test: r/X P°' Program,1 11 C,Rely ,N 27 9 -1611 i.,e
(gPm)
136.Diaiufection type: 70%HTH Amount- OZ DATE 517E VISITED:
,, 7qk-12 NV 4. 3 3 ZO
I
VISITED BY:_ F-.Jq ZIA
Farm GW-11116Nwth Carolina Department ofEavirontrenlal Quality-Division of WaterResoun es Revised 6-&2019