GW1-2023-00686_Well Construction - GW1_20230113

'CONS ITRUCTIION RF CORD('GW-1) For Internal Use Only:
1.Well Contractor information:
IA/ . ftKOWATERZOMSWell Contractor Nem�5 -- AtbhK 61a 9 el ►'^NC well contractor Certr6catiaxmnba
u mnla-need walla RLINEE de GubleYADIaN WELL COMPANY,INC. n1AMi1WtTBICE?mas MATERIAL
ComPmYNemeR 6,1 S in.33�Wq-74or .1NNgltORTUMG close&lea
2.Well Construction Permit#: Otr/7Q -L022 PRoM TO DIAMMTR •m•fficlOra9s MATmt UAL
List all applicable well construction permits(La r1JC,Couno,Sme,Yar/mm do) fL IL ice.
3.Well Use(checkwell use): ft ft. n'
Water Supply Well: 37,SCREEN
MM1 TO Ar DWA1c= S1. S= TIOCIOWS I MATERIAL
❑Agdcultmal icipallPublic ft. ft. is
❑Geothermal(Hestaip/Co ❑oling Supply) jdential Water Supply(single) . R ft, ice.
❑IndustriallCommercial ❑Residential Water Supply(shared) IE GROUT
❑Teri ion ❑Wells>100,000 GPD FROM I To I MAmm9J1W. I nMP CZKIATMETROD&AMOUNT
Non-Water Supply Well: .� '�(
[� ft' 3 ft' a ••. in ae t
❑Momum mi; ❑Recovery It. ft
Injection Well: C,
ft R
❑Aquif'v Recharge ❑Qroundvrckr Rionedietion
19.SANDIGEAVEL PACE da livable
❑Aquifer Storage and Recovery ❑Salinity Senior PROM To I MATERIAL. I F.MPLtcnMNTM6rHOD
❑Aquifr Test ❑Stmmwater Drainage R R
1311gerimeatal Technology ❑Subsidence Cmml R fL
❑Geothamal(Closed Loop) ❑Trans 10.rrRw.roNG LOG attach additional sheets ifnecesa
❑(Ieothermel eatmg/Cooling Ratan) ❑AOmer lainUndder*21 Remaska) EROM To DWCRUFTION wior hardy roshvrA etr.
4.Date W ell(s)Completedi� mt i _a`WellID# /(fir' .o� 6 ft gA; >„ G�ce . ck
5s.Well LorRtioa: ���Z��
Phone #el . V7/.? 3O R Lt R 'If ar
AAq� herry I'It It o R I It It. / t
Famlity loownerName �i,-iayme/ 10 St L ft'
yOCAa
R fL
Physical Address,LID,,and Zip I' ft ft
Ri.CY!'a.lh
Coomy Parcel Identification Na(PIN)
5b.Latitude and longitude in degreeAMnutes/seconds or decimal degrees:
(dwall field,one lablongis snm©ant) 22.Cer' tion:
3C pg' S7.S'b N Ab' .ir/ '!/.�"/� W
6.Is(are)the well($): 1ldermaneut or ❑Temporary a CatiSed well Contractor Date
gningthisfom%l hereiry crrO that the wells)was(were)constructed in aorordance with
7.Is this a repair to an eristing Well: ❑Yes of o 15ANCAC 07C.0100 or 15A NUC 0IC.0700 Well Construction Standards and that a copy
1f this is a repair,fill out Mown well conshuclion information andaplabi the nature of the ofthis record has been provided to dhe well owner.
repair under 1121 remade section or on the back afthis farm.
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 inprovide additional wall construction info
W tuns etimD only 1 GW-1 is needed Indicate TOTAL NUMBBR of wells (add'See Over'in Remarks Box).You may also attanh additional pages if necessary.
dn'lled: I ^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �O (ft)
For multiple wells Itat all depths If liml leramPlo-3Vo 100•md2@1001 9Dhmtt this GR'-1 within 30 days of well completion per the following:
l0.Static water level below top of using: P� (2) 74a. For All Wells: Original farm to Division of Wata Resources (DWR), _
10.St r teve It above el bet use op // Lofnrm b.Processing Unit,1617 MSC,Raleigh,NC 27699-1617ywole A
ll.Borehole diameter: (in.) Bit Off- (a r b L 24b.For Injection Wells:Copy to DWR,Underground Injection Control LIUC) `
Program,1636 MSC,Raleigh,NC 27699-1636 AIR ROTARY
S
12.Well construction method: 24c.For Water SuDDly and ODen-LooD Geothermal Return Wells:Copy In the
(i.e,auger,rotary,cable.diet puck,ale.) county environmental health deparmient of the coUnty where installed
FOR WATER SUPPLY WELLS ONLY: A 14d.For Water wells producing over 300 000 GPD: Co to D Q
3 !'l' Parr g am,1 11 MSC,Raleigb,NC 27699-TT Copy CCPCUA
13a.Yield(gpm) Method of III�� I,� ` _ 7(5
13b.Disinfection lype: 70%HTH Amount: 1 OZ DATE SITE VISITsE�D,:�t�7- 2t - Z Z-
- -- VISITED BY: I,/IILf _