GW1-2022-00154_Well Construction - GW1_20221219

�-Wf EL CONSTRUCTION I2>t!,CORD ('GW-1) For Internal Use Only:
1.Well Contractor Information:
y �/ W &W/1 14.WATER ZONES
We➢Conaactor Name m TO DISCSOMON
3v36 A �' R � R
NC Wen Contractor CanificetinnNumber is fL ffo
]S.Olyl'ERCASAIG nor mold webs ORLBHER ufa ➢able
YADION WELL COMPANY,INC. FROM TO OuammR rfficrassa DIATER]U01, it
R
CompanyN®e
pp 16. CA51t1G OE TUBING eothermalclosed-too
2.We➢CoastivCdon Permit#: 10M1koL 2.0022a2 .? " FROM TO nrAatBaTn 7— 1 MATelpAL
Lln all applicable well conxtruC ion pmnllt(ir.fIIC,Cm*.Sale,Ymialta W4 R ft I/ in. S V'`
3.Well Use(check well use): R R in.
17.SCREEN
w5per Supply Well: i FROM I To I plAMEl'R swrsae TmaOvrss Mw
akpicultural mpaUPublio B. la
DOeoth®ml(Heating/Cooling Supply) OdCesutentisl Water Supply(single) 1t. la.
Oli dustrud/Commercial OResideritial Water Supply(shared) IL GROUT
Olaf "on OWelis>100,000 GPD FROM I To I
ppMAmrw. I xnBUCHIMUNT ETROD&AMOONT
Non-Water Supply Well:
OMoniluring ORecovery tt R,
Injection Well; R R
OAguiter Recharge DOroundwater Remediation
19.SAND&MAVEL PACK N applicabW
DAquifa Storage and Recovery OSalinity Barrier FROM I To MAraarAi, I XUR—ACEaanNTM=011
OAgnifrt Test ❑Stotmwater Drainage fL '$-
DExperimental Technology OSubsidence Control it•
OGeothennal(Closed Loop) OTracer 20.DRILLING LOG aaaeh additional sheets ifuecetsa
DGeothermel eating oliag Return) 00dw(explain imder#21 Remadt) FROM m mscT�noN rnmr,sa.4nev.saniaaea arrz,ur.
�l (art a ft
4.Date Well(s)Completed: �aL'�-�ZWell ID# 1'#C1�- 3 R 6/a R
Sa well Location:
Phone # - 8- 7 R R
ft 1L
06'� nit y
F.-MYlOwna ame PeerlityID#CIfapptieable) R R
cc, �hl� 1=�( kj✓L R ft �n7
P4sicd Adds+.,City,and lip R R " L1a27
21 B,Eaienxa
uv _
Pared Ideatifioati®No.(PDi)
5b.Latitude and longitude in degrees/minutes/secouds or decimal degrees:
(ifnwe'll field,one lat/long is sufcieut) 22.Certification:
W O 17. 'OOC N �' �'7, 3 V 2 W 01� ����-.--- /2-
6.Is(are)the wen(s): n4manent or OTemporary 911guatareof Certified Well Contactor Dare
/ Byslgnuugthisfam,lherd lify ry cerrholthewell(s)was twere)cmutructedln accordmorwith
7.Is this a repair to an existing well: Dyes or t41Qo 15ANCAC 03C.0100 or ISANCAC 07C.0700 Well Construction Standcrds and thm a ropy
Ifthir u a rrpalr,fdl oul brown well conxtruc ion bnfmmahan and explain the nature afthe afth6 record has been providedlo the well owner.
repair under 421 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
S.For GeoprohdDFT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
coustuc tum,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add See Ovel in Remerls Box).You may also stbach additional pages if necessary.
drilled [ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v O (8)
For mudliple wells list all depths lfdlgereat(arample-3®200'w d2@1001 Submit this GW-1 within 30 days of well completion per the following:
St below top of wing:: ADO ( ) �• For All Wells: Original form to Division of Water Resources (DWR),
30.Static water level
10. r level Is above eJ buel are"+" Information ProcesvmgUnit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: C (in.) Bit Off: &/3 8 24b•For Taiection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
lx Well construction method: AIR ROTARY
cable direct 24c.For Water Supply and OoartLoop r t Geothermal Return Welk:Copy m the
(r.a mgr.rotary. pmh, ) rsamdy environmental health dcpartiuent of the county where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water Wells Droducing over 100 000 GPD:Copy to DWR,C(RCUA
t Pemut gram,161]MSC,Raleigh,NC 27 99-1 11 Y%OLACj
13a.Yield(gpm) 7S Method oftest: PQt A/#-
13b.Disinfection type: 70%HTH Amount: 3 y OZ DATE SITE VISITED:�'/�- 2 Z
T)ri cP e _ VISITED BY: M Q