GW1-2022-09507_Well Construction - GW1_20221014

1.WLr4C01V5 111FtBJCTId)1V RE COIPdi P f W-11 For Internal Use Only:
1.Weil Contractor Information:
14.WATER ZONES
FROM I TO I DFSCRMTKON
well Contmdor ame
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NC wen Contractor CutiSeationNrwba R aG -V"' ?0 SAt a sL 4C
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]S.OUTHR CASING for maltiKased OALINER der Gu61e
YADIGN WELL COMPANY,INC. Faoat m nuauxen Tmtsaass auxawAL
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CampmyName lt��l /'_�� SSG- GtLs- ?el3 16.DINER CASING OR TUBING eothermal rhued-Too C'
2.Well Construction Permit#: Z-Z O?-/�/A//'/Q.-OTI00 7som To nlAelSrsR THiC@>d.46 auTamAr.
Ltd all applicable well construction permitr(tr>nG County,Slats Varlana,ale) R R 1°' ,SQK•�y( Pre +�
3.Well Use(ebeckwdl use): fL
Supply Well: 37.SCREEN
Water Su
PP Fnoar ITO I nrAa1C1'SH sl,oTsds T'IDOIN[as esnrtauAr.
DA riwltural ❑oiunicipal/Public % ft. In.
DGeothermal(Heating)Cooling Supply) P fesidential Water Supply(single) R R, is
Olndustrial/Commerciel DResjdeutial Water Supply(shared) 14 GROUT
131crigatica DWells>I OQ000 GPD FROM I To I MATZRIAr. I UW ACEMENT RMTHOD&AMOUNT
Non-Water Supply Wdl: 40 ft. O R
❑Mnnimring DRecovery O R '� tL pe,:S�//
Injection Well: fy g,
DAgmfer Recharge OGroundwateer Remediation
79.$AVID/GRAVBS.PAC$der linable
DAquifer Storage and Recovery OSalinit}'Baer 10IOM To 1lATSR1Ar. SI�IACal1!@.trr 117H,18 w on
DAquifer Test 0Stormwster Drainage R IL
DExperimental Technology DSubsidance Control R it.
DGeothermal(Closed Loop) DTracer 20.DHILLDVG LOG attach additional sheets if necessary]
DGeothermd(Heatmg/Coo' m Rah=) DOther(explain under#21 Rr ld® � To R o:nos so RTrIl
rotor mNam.mv,vrk err
O R g
4.Date Well(s)Completed:9/lp•�1 WdIID# ��212' ` ti' 3r R' �4
Ss.Well Location: G..a4I - Ow.yhJet j R 7� IL ..S a
Phone # 33Cr U- gYk7
ti b R y3eR eel ie
gsrc,.aa c>ofia�a R R
FecditylOvvaaName FaelityMP ff applicab la)
�'� LQtA✓Y� �Ce'Wr� 1-lCoffU/1rC R R
Physical Addrra(�City.(and Tap R R -
KI I Z'.C 21.REMAa89 _
Cow. Parcel Tdenti5cetion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwa0 fold,we 1st/longis sufficient) 22.Certification:
3S' S7.'3GPb.N 77'0 W17? w are✓7 t �! 9-l� ' 0� 3
6.13(am)the we0(s): 14ermaneat or OTemporary Siq^of e0 Coauaamr Date
Byslgningthirform,Thereby cer(tjy that the well(s)was rwerg)contracted in accordance with
7.Is this a repair to en existing well: Dyes or ILiQo 15ANCAC 07C.0100 or/SA NClC 02C.0200 Well Construction Standards and that a copy
ljthtr 4 a repair,fdl ant known Weil constsvcdon brjormadw and explain the nature of the ofthlr record has been provided to the well owner.
repair under 921 ramaria section or an the back ofthisjorm. 23.Site diagram or additional well details:
S.For Geo robdDPT or Closed-Loop Geothermal Wells having the same You may use flu back of this page to provide additional well construction info
construction,only 1 GW-1 ins needed. htdicate TOTALNUMBER of wells (add'See Ovd em in Rsdm Box).You may also attach additional pages if necessary. !
drilled: i , 74.SUBbMTAL INSTRUCTIONS
9.Total well depth below land surface: 2141 A) Submit this GW-1 within 30 days of well completion per the following.
For multiple wells list oil depths Ijdiffeamt(example-3©100'and2®1007
24s. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (1W Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 Q
rwater level is above=btg use"+" r
Bit Off: •©s/7 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: _pa.) program,1636 MSC,Raleigh,NC 27699-1636
)Z.Well construction method:
AIR ROTARY 24e.For Water Sunnly and Oven-Loop Geothermal Return Wells:Copy to the
(La.anger,rotary.cable,direct posh,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producIng over 100 000 GPD:Copy to DWR,CCPCUA
a 14 Permit gram,1611 MSC,Raleigh,NC 276 -1 11 M)s}p ll��AA�� f
]3a.Yield(gpm) Method of feet:
9
13b.Disinfection type: 70%HTH Amount •y OZ DATE SITE VISITED: I
VISITED BY: D'=