GW1-2023-00687_Well Construction - GW1_20230113

IX�1316TONS TIRUCTION RECORD QW-ll For Internal Use Only:
1,Wji Contractor Information:
14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION
.3 23DIt
ft. ft.
NC Well Contractor CartificationNumber JAN C. CASRYG0br!uJ1i-czse.dwells)ORLIN)KR(ifap Ucable)
TO 'DUMTM YAOIUN WELL COMPANY,INC. l+G4_1 ft. I jUmble j)
CDMPauyN=r
in- Ll Pu e__
16.RWM CASING OR TUBING(geo closed
-7,<- pu
2.Well Construction Permit#:_nc FROM TO D1"MrnR THICKN MIS 1% 1
List all applicable well construction permits(4a.EffC,County,State,Variance,eta) ft ft in.
3.Well Use(check well use): E ft., in.
Water Supply Well: 17,SCREEN
FROM TO DLkMrrLR SLOT SMr THICtQIESs MATERWI-
DAgricultural DMunicipal/Public ft. ft.
DGeotheimal(Heating/Cooling Supply) k(esidential Water Supply(single)
ft, ft. in.
DIudustrial/Commercial DResideritial Water Supply(shared)
IS.GROUT
DIrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft gy
0monitodug EIRecovery ft.
Injection Well:
ft.
ElAquifer Recharge []Groundwater Remediation
19.SAM/GRAVEL PACK ffappUrable)
OAquifer Storage and Recovery 03alinity Barrier FROM TO I MATERIAL T-EAiPLAcE=NT?&=. OD
DAquffar Test IlStormwater Drainage ft.
DExperimental Technology OSubsidence Control ft. ft
00cothennal(Closed Loop) OTracer 20-DRILLING LOG(attach additional sheets ifneressary)
I DGeothermal(Ileating(CoolingRetxm) 00ther(explain under#21 Remarks) FROM To
4.Date Well Completed:91/D&/aro-Well ID 50 ft. -56 ft. of
-f. 6® f'- 6mo, 4 R c,e-k
5a.Well Location: -71
t Phone 1-41 f" ' f" j 6w-,i We W ta-
Uja*C_ -M0A'4f.^ &i W&L-d,,w '-)I f' 10 X f L 4,A-y '�' /-c� e�- Lle_V Gil,e-
Facitty/OwnerNamL Facility ID9ffqpIicabIq) ft ft it I
Couck's ft. ft
11bysical Address,City,and Zip ft ft
21.REMAPM
County Parr el cation No.UM)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Si 'e T Contractor
ing thisfur774 11hareby certi)�that Me well was(Hiere)constructed in accordance with
g i J
y ce CAC 02C.010D or ISA ff'
(if well field,one lat/loag is sufficient) '1AJ0 .111nn, MC 02C.0200 WEII Construction,Standards and that a copy
'ciant) 22.CeitIficatio
6.1s(are)the well(s). INPermanent or OTemporary Si re C 0 Contractor Date
7.Is this a repair to an existing well: DYes or Mf, ,hereby
I N r n,
If this is a repairftl out)mown well construction information and explain the nature of the of this record has been provided to the yell owner.
repair under#21 remarks section or on the back of fhiijbm, 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
construction,only I CTW-I is needed. Indicate TOTAL NUNMER of wells (add'See Oyer'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SU13MTITAL E%6TRUCTIONS
9.Total well depth below land surface: Submit this GW-1 within 30 d '
For multiple wells list all depths If&fferenl(example-3@20D'and 2@1 OOD RYs Of Well completion per the fallowing:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),—
lfwater level is above casing,use Information Processing Uriit,1617 MSC,Raleigh,NC 27699-1617
ryry
11.)Borehole diameter: (in.) Bit Off. 611 24b.For 11kiection Wells: Copy to DWR,Underground Nection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Wells Copy to the
ry(ie.auger,rota ,cable,direct Push,etc) county environmental health department of the county where Vt-lgln
FOR WATER SUPPLY WELLS ONLY. 24d.For Water wells producing over 100,000 GPD: Copy to DWP,CCPCUA
13a.Yield(gp-) 3 Method of test. Perm 1EP—rogram,1611 MSC,Raleigh,NC 27699-1611—
13b.Disinfection nfection type: 70%HTH Amount: Oz DATE SITE VISITED:
-Pri re; VISITED BY: