GW1-2022-00164_Well Construction - GW1_20221219

NVEi.1 CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: Q
U.WATER FAIVF9
Well Cunbac Name 7- TO DL4CRII710N
ft. R
3016A�- /is ft- fyr R Ierr
NCWdleouaaeto<a»fficmhcnK
35.OUTHRC rmdfiKated wens ORLINERicows
YADION WELL COMPANY,INC. FROM nUKURR
R
Company Name
!1 f� 16.B'0'0*1t CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: (/ L J( EOM TO DIWI z TOM-
ffictays ,
11a all applicable well construcilon permltr(Le.=Cowry,State,Yariwce,eta) � ft fL m. S•
3.Well Use(cbeckwell use): R fL
Water Supply Well: 17.SCREEN
FROM TO DMIErER SLID[SIZE
❑Agricultaral CMnmicipal/Public
OGeotemral(liearing/Cooling Supply) identiah Water Supply(single) ft.
�Indnsbial/Comrnercie] []Residential Water Supply(shared) a GROUT
Ellaigation OWells>100000 OPD FROM TO MATIPJAL EMPLACEMXNT METHOD A AMOUNT
Non-Water Supply Well: ft I RCIL-Mr
w•
DMrmitormg ORWANCry ft. R
Injection Well:
R fL
OAquifer Recharge DGrrnmdwater Remedietioa
OAquifer Storage and Recovery DSalmity Banner t �OSAND/GBAVELPACK MA•mer.r.e E NTMElHtm
DAtImfer Test OStmmwater Dramage R . ft.
DP.xperimenfal Technology OSubsidence Control
OGeothe®el(Closed Loop) OTracer LOG L _ 20.rmw.r.DaG L attach additional sheets if necessary)
OGeothermel eating/CooUn'�g'�Behan)'� OOther( un lain der*21 Remade FROM TO r�Dasnox ram saeaaesa r, ,waboek s eta
fL Sol
1PIL
4.Date Wel](s)Completed:1. well Wk�14Rw(,e',L O fL �O ft.
e
Sa.Well Location: Phone 0 P-9 r7` W ft ft
) ft.
/Zau L/tAoGNnr ^/gat,`(
Fadity/ erName� Pecdity IIM'(d pplicable) R ft.
Pbyaed Address. .and Tap � ,h)(( / R R 0...
23 BEMARKE
/�� G
County Peteel Idem cation NoQ?II•l). eiemw
5b.Latitude and longitude In degreeshninutes/semuds or decimal degrees:
(if wall field,one lat(loug is sufficient) 22.Certification:
3�
6.Is(are)thewell(s):Permsa=t or DTemporary Sirn&re of Catifia WR Contractor Date
Bya/gnbigthisform,lheraby certify that the well(k)was were)cnrs credfn accordance with
7.Is this a repair to an ndsting well: OYes or x1ND 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Consaudiw Standards and that a ropy
ythir is a repair,f01 out known weR conrhucdon Infomration told erpla/n the nmurc ufthe of this record has been pmidd to the wall swan.
repair wdn471 mmffkrseNw or w the back ofthis form.
23.Site diagram or additional well details:
S.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
constructica,only 1 1 is needed Indicate TOTAL NUNMER.of wells (add'See Over'in Remade Box).You may also stter3 additional pages if necessary.
drilled GW-
: 7 7.4.SUBM1TfAL INSTRUCIIONS
Q a� i
9.Total well depth below land surface: 1 a� d (R•) Submit this GB'-1 within 30 days of well completion per the following:
Fn midtple wall,list all depths Ifdfferwt(sample-3®100'wd2®l007
wtopofeadng: 3o (TI-) 24s. For All rm (D Wells: Original fo to Division of Water Resources WR),
30.31aticwaterlevel below d
InIh mabon ass Proe 'h4 Unit,1617 MSC,Raleigb.NC 27699-1617
lfwaw level Is circle el bel use "+"
11.Borehole diameter.• b (bL) all Off: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC,) GeQ�
Program,1636 MSC,Raleigh,NC 27699-1636 T
72.Well construction ROTARYnstrnctioa method: 24e.For Water Suonly sad Opra-Loop Geothermal Return Wells:Copy to the Is
(ia roger.many,cable,used posh,etc.) county mvnomnental health deperuneot of the county where mstalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducia over 100 000 GPD:Copy to DWR,CCPC'JA
Peraut Program,1611 IVIS Rslei ,NC 2 699-1611
13n.Yield(gpm) 3 o Method oftest: Q/lY
136.Disinfection type. 70%HTH Amount: q OZ DATE SITE VISITED:
A�
Pri r•a•
VISITED Sr.. 0/0