GW1--03438_Well Construction - GW1_20230516

liVflarCONSTRUCTION RECORD(G'W-1): , ' For Internal Use Only:
I.Wcti• :meter Iiifornintion: •
, .../146,,,a, __ 4/'0 Wel. _ . _ ... ,
,
_ . _ - . „ .
, 14.WATER ZONES.' -:• ...-'t. ::., , . ''
FROM TO . . DESCRIPTION : ' ` •
Well Contracttir Name
. 3d 36 4 - - ft ft
• 1 I g • : 1,20 .•--.utit, : .. ,FS;/99- zocf,,,
136,r fL :1 37 -
NC Well Contractor CeiiifidalionNuinber ' 15. •
OUTRR CASING(for Malik:ea Viells)GB.LINER(if ap hr.able)
YAUKINVELL COMPANY„INC. ,TER. , TEa , MATERIAL
emPanY*me .
S414stel 17‘.- :r g3-1-4.43 l 16.INNERINNERCASING OR TUBING(geothermal closed-loop)
2.Well ConstructiOntermit#: a 791 . FROM ;TO DLILIKKIER. . TEaCKNOSS • -MATERIAL
List all,applicableweltconstructian permiti(Le:Ule,Celan(y.Slate,Variance,etc.) ;4- I ft: 1.a g ft. .6-r/r Tin. oiis,T18 ' o.iv 3.Well:Ilse(checkwell!use): f!••• rt. . -- , in. - • -
. _.
•Water Supply Well: '- - - •. 17.SCREEN
,_mom_ i TO DIAMETER. .SLOT SIZE - THICKNESS MATERIAL '4'----,
DAgriMiltural OMtuticipal/Public ft. ft. In. ((1'
IDGeetherrnal(Heating/Codling Supply) Ctlidsideritial Water Supply(single) ft. . f ' in.- ' ... 1 •• . Z:3*
DIndushial/Cbitunernial • . OResiclential Water Supply(shared) la GRoui.
Olirigation-_ f .- . _ _ CIWells>100,000 GPD , , FROM' TO MATERIAL • EMPLACEME'NT METHOD&AMOUNT
NowWater Supply Well:. . .0 ft rftr:f. ' ,
DMonitOring OR.enovery ft. ft. •
. . . . . . _.,
Injection Well: (5
, Sq., 4' .. .
0Aquifer Recharge DIGroimdwaterRemedialiOn , ,. ft. S. /1?- C 6
. 1.9.SAND/GRAVEL PACK(if applicable)
OAiluifer Storage andiRecovery OSalinity Barrier , FROM TO MATERIAL _ _ EMPLACEMENT DIETROD i 1
ElAqUifer Test 1:1StOrmwater Dtainagt
Elbqieriimental TtehnOltigar IDStibaidettce COMMI , 's, .....'
: ..•:• '•/• ., '..... r ft. 11(..: , ,
OGeetherinal(Closed Loop) Mincer ' 20.DIMING:LOG(attarli,additional sheet If necessary) -• : '
, •PROM. _ 1 TO - DESCRIPTION(color,brullness,soilkor.ktype,grain ace,etc.)
;I:Geothermal(Heating/COOling Return) „.Dottier(explaiit oclir-#2_1 Rogar_lcs); • ...., _. , ,, .
S4,41/40 : 4/1 z];21 c..._, •. .(;), n' ; -T-7. . 1` .-Yo,ti. ..
. . . .
4.Date•Well(s),Conipieted: al//2,,/21. WellEili•AAP-473%j ' S ft'.;! 9-f- rta --56frieli4i2/. Wittogiirse irfa;zt 'Co /, ;e
5ILWellLotriticin:. Ptiono:#°fig-_21,5_q I recl_ _937 .,?0.2.
- ' ' ft- Ad/ikLet. ..6_,-i.,,9,0- , -
Cell'e.1,. 414" ...: ,_ _ _ . .. . . .. . - ft.
._ ft. • •
Pecilitiri0Vmer Nagle, PacRity IDA'(if applicable): .. . ,
-
. _ , ar.a.A: . ' (A. ._, -.14_ _ 0 12 C Ot)) .e _ _ -
/0-.:,.570. ig - -,,.t r L , -r-- 4 c It f„ ,_... ft. , ,..... .....,.., ,1,„.._ ;.,,, .:4---,:.
_.., . (.....,.,.,...i. v. Z__A.,..;
Phystal Addles-ei dill tuadlip, N't alC6f, •
_ _ _ ,. , 21-„REMABICSH _ - - , 'MAY '1 :,!'2023'';. '''.
Wes..-- - - -- - - , J./ 1.__071-•' . . . ...
County• Parcel Idendealien .(PIN) -4eA--,-- 0 z g cm.'r - 1 sl C,;;;;,:Tr,-e-.;"n 2!.- 1-1',1
, L - ' '; ,,T,.'r.'4'.,,,TC:P3 09,,.:-,,:.•-:-
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:'
' (itivell field;one lattlongin aufficiett)' 22,Certification: . ,. , , , . ..-„ -
. . .
. . .
1 324 N R.4 7 2,1.1 2.67. _ ._ . . w .. . .
'-.2/23
Si atcre,of Certified Well Contrector . ,-,•,'. --'; ,., '.-: ate.
6,Is(are).thelyell(S):. Ill‘rnitient or OTemporary
By signiitthisjirm,.7 hereby certil,that the'well(s)was(were)constructed in accordance with
7.Iii,thiii a repair Mit existing well: .13Yes or altr: 154 NCAC 02C'.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If thfris a repoir,fillioutkti owit well tanitructioiS iirfOnnaticin-and esprain,the nature of the of this record has been provided to the well owner. •- '. i'
repair,under#2.1?remarkssectiOn or on the-back cif this fonn. 23.Site diagram or additionetwell details::.•••.:.•.• •
You may use the back of this-page to provide
' additional well construction info
8.For Geoprobe/DPT or Closed-Lodp:Gebthermal Wells hitvingtlie same,
constructical,only 1:dWil isineeded..IndibateTOTAL NUMBER of Wells' (add'See()V&in Remarks Box).You may also attach additional pages if necessary.
dtilled! ... _ _ _ _ - _t_ _ ___ .. . 24' SUBMITTAL INSTRUCTIONS ' '.. ' •‘, • '
9.Total Well depth WOW land surface:_ cv2 02 _ _., . (fi.)
Submit thi's-GW-1 within 30 days,of well completion per.the following:
For multiple wells list all depths.ildifferent(example-3©200'and 2(4)1007
„, , 24a. FOr All Wells: Original'.fort to Division,of Water Resources ,
10.Static water leVellieldW top of Casing: . 20 (It) InformatiOn Prodessing Unit,•1617 MSC,Raleigh,NC 27699-1617 (DWR)
Ifwater level's allelic casing use"+"
Bit Off: 64 if 3: . • 2Ab.-For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
• 11.Borehole diameter ... _ C.• . _ .: (it.) - Program,1636 MSC,ReleighNC 276994636
" • ' •
12.Well constructionAIR ROTARY
Method:_ _ 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.c.auger;totarAdahle.died publi,etea , •, .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,161.1 MSC;Raleigh,NC 27699-1611
110 •130:.Yield(glint)- _ . _ . .....,Method.of test: ri , a(,r. nz J4give., rd
07 'Ye HTH' oi SITE VIBITED!:-2-4j,-2-3 ..b.r
,13b. is eon type: Amount: . DATE'2,:,..;_
...._. ...
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VISITED BY:- nO - -in !•
, . AP
FiUm OW irenmental Quality-Division ef Water Reseerces
, Revised 6-6-20l 8