GW1-2022-00247_Well Construction - GW1_20221216

"WELL CONS I^1�i1U'C 111ION RECORD(GW-11 For Internal Use Only:
1.Well Contractor lnforinntion: _-
3 CX C T_/ . 1 k l V%S 14.WATER ZONES P
L� FROA4 TO DPSCRIPTIONWell Contractor Name ft. ft.
eP Li 0714 ft. ftNC Well Contractor Certification Number 15.OUTER CASING forVulti-casedwells ORLMMYADKIN WELL COMPANY,INC. FROM To DL&MUTER TffiClffiEft. ft in.Company Name 16.INNER CASING OR TUBING( eothermal dosefl-to2.Well Construction Permit#: v 4 / ` UFROM TO DIA&M= TE[ICIMU �y
List all applicable well constructlonpermits(i e.UIC,County,State,i�ariance eta) 4-Pt 9& ft G Vy in. spR'9t [-d L-
� ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM I To DIAMETER SLOTSIZE TSOM-SS MATERIAL
❑Agricultural DMunicipal/Public ft. it. in,
❑Geothermal(fieating/CooIing Supply) Akesidential Water Supply(single) ft, ft. in.
❑Iudustrial/Comroercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: ft' Z 1 ft Hole X 060rn) it
❑Monitoring ❑Recovery ft ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAP1D/GRAVEL PACK(if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TD MATERIAL ENIPI.ACEMI NTMET�OD
OAquifer Test ❑Stormwater Drainage ft' it
❑Experimental Technology ❑Subsidence Control ft I ft
❑Geothermal(Closed Loop) ❑Tracer I20.DRML'NGLOG atfachadditionalsheetsifnecessa
FROM TO DESCPJrnON color,hardness soi lreek S s6r.°M:
❑Geothermal(Heating/CoolingRetum) [I Other(explain under�21 Re2marks)/� ft. �.S � Qtr
4.Date Well(s)Completed: 11 Z� �J Wel1ID#A LIT & 112z ft e,r+-m,yr
ft
5a:Well Location: Phone # 3 3��4 0 3 ft " �A ^,`"
1"N G G t!T/"`l
Facility/OwnerNpa�m�e - fj '•I /FacMylD9Cifapplicable) _/� % � F '� n �n?d
C.)CZfJ ft llli o':a:�;:. t :•J Y :1
_ GC
Physical Address,City, don Zips ft ft r' a:1 i.�
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minnteslseconds or decimal degrees:
(ifweilfield,one lat/longis sufficient) 22.Certification:
6.Is(are)the well(s): ermanent or ❑Temporary sigoator of Cerw Well Contractor Data
By signing thisform,I hereby ceroThal the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orT0 15ANCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a copy
et
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner
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 needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarlm Box).You may also attach additional pages if necessary.
drilled:, a 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y 7Z (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths(different(example-3@200'and 2©100D
7(� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
III.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
Bit Off: to•�S� 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.13orehole diameter: (�) Program,1636 MSC,Raleigb,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
/ Permit Program,1611 MSC,Raleigh,NC 27699-I611
13a.Yield(gpm) Method of test: )
70%HTH "� OZ DATE SITE VISITED: 1 D —�—� Z, \\�``_�41
13b.Disinfection type: Amount _ (�J
--- - - VISITED BY: ��