GW1-2022-10364_Well Construction - GW1_20221115

Agll,�+CQNS TR UC JT IQN RECORD �GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
=7 ". 91 c" ft. Y)L-
Qr
7 9- A a?f ft. 'A 917`It
NC Well Contractor Certification Number � 2 �
15,OUTER CTIN for muniti-rased w ells Nifoble
YADKN WEL COMPANY,INC. rART7D
MATERIAL ,
ft. R in.
Company Name 16.INNER CASING OR TUBING eothermal rlosed-loo
2.Well Construction Permit#:_P(Zwl.olea�l�d��I'�- FROM TO DIAMETER TffiCIQIEss MATrii�i.
List all applicable well construction permits r,e.UIC,County,State,Variance,etc) -t-` tt. '7 a ft j; v in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
FR011t TO Drwnssrrs•fl SLAT SIZE THICIMSS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) W esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
Non Water Supply Well: 6 ft- .3 ` ft. a Nret
❑Monitoring ❑Recovery 3 ft -
( It. eq ow,Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a Gcable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPI.ACEMENTr1 MOD
❑Aquifer Test ❑Stormwater Drainage ft ft-
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLTIVG LOG attach additional sheets if neemsa
FROM To DESCRIPTION color,hardness,saillrucktyp4 grain sue,etc
❑Geothermal(Heating/Cooling Rctum) ❑Other(explain under 421 Remarks) 0 ft &0,ft. S�D;L
(7 4.Date Well Completed: -� - 2,well im A//T 10' 22�" 6' ft• 39.11L /,k V J12o
5a.WeU Location:✓1 /Phone #35(�.6YP-3721 fL ft. r
4 AMIL C. WI�1�1, ft ft 7 .�
Facr7ity/Owner Name Facility ID#(if applicable) ft f r LQ22
112 s-,� s4mL ete lit rel E(1<(►, ft ft
1rliJfiala3,IC�1 � ^^ ��,.••.
Physical Address,Cdy,and Zip ft ff. rr1V,'Q'3OG
21.REMARKS
Sulr✓v
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
36 a /8"s '7 t N $,0G `T, Zr-3 w A
l®-21
6.Is(are)the well(s): 114?"e"rmanent or ❑Temporary Si re of C&Sfied Well Contractor Date
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordmmce with
7.Is this a repair to an existing well: ❑Yes or Wfo 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
1f ihis is a repair,fill out brown well construction information and explain the nature of the of this record has been pravOed to the well awner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is ngeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: I 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �7 ep.� Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdi$erent(example-3()n 200'and 2©100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:_ �Z t" (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If waterleve!is above casing,use"+"
f Borehole diameter in. Bit Off. 24b.For Iniection Wells: Copy to DWR,Underground Injection Control (IUC)
11. Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,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
13a.Xield(gpm) Method of test: �+�a`1 Permit Program,1611 MSC,Raleigh,NC 27699-1611 Ar
//'
13b.Disinfection type:
70%HTH Amount: S'� OZ DATE SITE VISITED: � 10 -ZZ. l
�,�-
VISITED BY:
Fnrm GW-1 0 al -fli Cnmlinn Drnartment ofFnvimnmental v_._._a c c im v