GW1-2022-00021_Well Construction - GW1_20221219

r9M CONSTRUCTION RFCO D fGW-1) For Internal Use Only:
1.Well Contractor Information:
re,, J erbw•e, 14.WATER ZONES
Well Contractor Name- FROM TO 0715CR1P770N
3 4r" fL ft o + t+1 T
n ft
NC Well Contractor CerCSoetion Number is.OUTER CASING for multi-cased wells OR LINER da licaWe
YADION WELL COMPANY,INC. RROM TO 11mmurIER TffiCgi S MATERLII,
Company Name tt ". . 1 in. R�i
p� � 16.IIiPIER CASING OR TUBING m theral closed-loop)
2.Well Construction Permit#: 212 ,A/L 7-J21 O 0 C r I PROM To mAM H I THILTOiLss haATERtAI.
Ursa//applimble,well conmuctlan PermitsA&UIC,county.Stale.Farfanm eta) R ft.
3.Well Use(checkwell use): R. ft. ice.
Water Supply Well: 17.SCREEN
FEOM i0 D1AMEfER I SLAT SIii TBTCENFSs MATERIAL
CAgriculmml mpaVPublic R.
CGeothermel(Heating/Cooling Supply) L91Cesidential Water Supply(single) tL ft. in
Cludustrial/Commercial CResidential Water Supply(sbared) I&GROUT
Dili 'on Dwells>100,000 GPD FROM TO MATERIAL EMPIACE 'r METHOD&AMOUNT
Nan-Water Supply Well: 0 ft. R / f
w fC
CMrmihiring ORxwery tt ft.
Injection Well: ft. R
CAquifer Recharge CGrouadwater Rimadiation
CAginfer Storage and Recovery CSalmity Bawer 19.SAND/GRAVEL PACK d applicable)
FROM 10 MATEarAr_ EMPGCEhI6NTMEPBOD
CAquifer Test ❑Storrawater Dnamage ft. ft.
CBxperimental Technology CSubsidence Control R. ft.
❑Geothemxa](Closed Loop) DTrscc 20.DRUZING LOG(attach additional sheets ifaeeessa
COeothermal McatinglCuoling Return) COther(explain under#21 Rem ics) FROM I To InFscaTPTTJON rotor,hardnm,,a0/ra,k a :Qe,em
�J /� j 6 R R So. T�.O Sc ,mot
4.Date Well(a)Completed: Aso A�WcIIID# 2� ft tt oC/ Q. <-.t {
5s.WellLocatiaa: Phone # ]T�-217-�Z6 S 5 R
11 w
S tier Con K ft ID tt t
Famlity/Owner Name 11-aity ID*(if applicable) O;L ft It is I, t1
630 �oM Nlin K4l� /�o� lK�h_ ft. R V'I
Physical Address.City,=it Zip fL ft
&4VIew 21.REMARKS - W
County PaulId, cation No.(P1t4)
5b.Latitude and longitude in degrets/minutes/semnds or decimal degrees:
(ifwell field,one lat/Iong is safficimt) 22.Certfiicati
A o
� 3' r S '7 N 90" 2 !G7. -70 a�
6.1s(are)the well(s): iIP'ermavent or OTemporary a arti5ed Well Conti'ntor Date
mglhlrform,lhereby nertifylhat he we11(s)was(wen)caubu clad 1n accardmras with
7.Is this a repair to as existing well: CYes or ONo 15A NCAC 02C.0700 or 15A NCAC 02C.0200 We11 Construct/on Standards and that a ropy
Ifrhis it a repair,fd/oul brown wdl c mhud m blformaam and mplabr rho nalure ofthe oflhls recordhas bee tprwided fa the well owner.
repairunder 021 remarks section or on the bock of lhfaform. 23.Site diagram or additional well details:
8.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
caustructioa,only I OW-1 is needed Indicate TOTAL NUMBER of wells (add'Sm Over'in Remade;Box).You may also attach additional pages if necessary.
drilled: / �D , 24.SUB71I1'Tl'AL INSTRUCTIONS
9.Total well depth below land surface: (fL)
For multiple wells list al/depths ydi$erent(emmple-3®200'mdd2®700') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwaur level is above casing are"+" lahnnation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: fca (in,) Bit Off: 614556 24b.For Injection Wells: Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
`
12.Well construction method: AIR ROTARY 24c.For Water Supply sad Opea-Loon Geothermal Return Wells•Copy to the
(i.e.anger,rotary,oabl0.duct posh,etc.)
wrurty envnoamenta]health department of the county where iustatled �
FOR WATER SUPPLY WELLS ONLY: 24d.� For Water We11.a roducli over 100.000 GPD:Copy to DWR,CCPCUA Q, Permit Program,1 I I MSC,Raleigh,NC 27 99-1611
13e.Yield(gpm) � � �' Method of fret: CaGrs.Y ,�uv
136.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED: Z
VISITEDBY: pall