GW1--04013_Well Construction - GW1_20230612

'd7 z;=,-t;-'y;'V�NSTI RIUUC TION LSE+iCO11�➢' (GlIV-11 For Internal Use Only:
I.Well Contractor Information-
14.WATER ZONES
Well Contractor Name FRold TO
DL�SCRUTION
y
��� aisit 66 a
ft. it
NC Well Contractor Certification Number
15.OUTER CASING for multi-eased wells)ORLMR if a livable
YADION WELL COMPANY,INC. FROM TO DiAMR1T{R TffiCEnvEss MATEWAL
ft. ft.
Company Name
A 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Rt�� � FROM To DUKE T1DECIOTEss MATERIAL
List all applicable Nell construction pe:mus(ix.TUC,County,State,Variance,eta) �'3 It G 1 fJ in. P%rC_
3.Well Use(ebeckwell use): ft. ft. in. Q
Water Supply Well: 17.SCREEN
I ROM TO DIAhIF rER SLOT SIZE THICKNESS MATERIAI
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal (Heating/Cooling Supply) Ckesidential Water Supply(single) g. ft. in. M
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -.11
❑Irrigation ❑Wells>100,000 GPD FROM I TO MATERIAL RMPLACEMENTMETHOD&AMOUNT 1P
Non Water Supply Well: ft. ft. 140`te PI poom 1 -ZQ J
❑Monitoring ❑Recovery :3 ft. a?
Injection Well: V
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK rf a livable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLIL W LACEtMNTMETHOD
❑Aquifer Test ❑Stoimwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLMgGLOG attach additional sheets ifnecessary)
FROM TO DESCRIPTION color,hardness,soillrock 4 grain size,etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#/21QRemarks) ft. SO ft
4.Date Well(s)Complete d: S �8 WellID# I �Q ft' '1'S�� ft ����
[ -I
5a.Well Location- A Phone# 3 244V-0tt� ft -
- ft. ft ' '' y°
%1:
Facility/OwncrName Facility ID#(ifapplicable) ° - ft. ft
3�R -ono ft �lti i v 2023
Physical Address,City,and Zip ft ft. is
Itli�ifi7,^sl�ca ,-rc.n:. ��_k
S'A e- 21.REi17ARK5 rM
County Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees/nunutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
! N ��L W
6.Is(are)the well(s):Aermanent or ❑Temporary Sign of CmPtifird Well Contractor Date i
By signing thisform,I hereby cer16 that the we/l(s)was(were)constructed in accordance with
7.Is this a repair to an existing well:, ❑Yes or )IND 75A NCAC 02C.01 OD or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out Mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair underf2l mmarkrsectionoron the back ofthisform. 23.Site diagram or additional-well details: -1
You may use the back of this page to provide additional well construction infD -c11����
g.For Geoprob y I G or Cln ed ed. I Geothermal Wells having the same (add'See Over'in Remarks Box).You may also attach additional pages if necessary. Se.,
construction,only 1 GW-1 i�needed. Indicate TOTAL NUMBER of wells .�
drilled: l 24.SUBMITTAL INSTRUCTIONS Cl)
9.Total well depth below land surface: »' (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdierent(example-3 c(�i 200'and2Q100D
10.Static water Ievel below top of casing: 3-'V0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), 1.
Ifwater level is above casing,use"+" Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off- �`7 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
(ie.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
13a.Yield(gpin) 11.1 Method of test: a�h Permit Prograrn,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: 70%HTH Amount: OZ DATE SITE VISITED:
VISITED BY: Uo
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