GW1-2023-00694_Well Construction - GW1_20230113

RECORD QW-1) For Internal Use Only: 0
I.well Contractor information: 0 .
1 14.WATER ZONLS
;We_llcontractor Name I FROM TO DESCRIPTION
7 P_
/a
ffi ft
iC Well Contractor Cmiffication.Number JAN Is.OUTER CASING for Trill16--il Wells) (ifzppl[imZbIe)
R"L
2023 11RU1111 I TO
YADKIN WELL COMPANY,INC. "" PET ss X&TERUL
ft.
. Z�
t. in.
Company Name
26.R;%4WM_R CASING OR G(geotherm2l closed-10073) ti
FROM TO PIAWM= THICIOR MIS ?,TATrIUAL
2.Well ConstructioriPrrmit#: 3 5? 0 1�1_ ---
List all applicable well construction permits(i.e.E9Q,CouifY,State,Fdriance,etc) ft. 6.3 ft. in.
3.Well Use(check well use)- ft, ft. in.
17.SCREEN
Water Supply Well: rROAT TO DIAMETERI-SLOT SIME-F-T-HICICNS ES MATERIAL
ClAgricultural OMunicipal/Public - ft. ft, in.
ElGeotliermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. ft. in.
Dindustrial/Cornmrrcial EIRcsidential Water Supply(shared) 18.GROUT
DIrrigatioz oWells>100,000 GPD FROM 1.TO MATERIAL EXPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: o I'- 0(o opC Pid Po 6aS
DMonitoring DRecovery ft ft.
Injection Well: ft. ft.
DAquifer Recharge oGroundwater Remrdiation 19.SANDIGRAVEL PACK if applirable)
cAquifrr Storage and Recovery 0 S aliaity Barrier FROM TO MATERIAL EMPLACrNm NT W=HOD
DAqnifer Test OStormwater Drainage ft. ft.
DExprrimental Technology oSubsidence Control ft ft.
oGeothermal(Closed Loop) OTraGrr 20.DRILL'INGLOG(attach additional sheets ifneressary)
FROM To DESCRIPTION color,birdnas,3o!l/rack�ipc�gr-.i7iusi=,etc-)
ElGrothormal(Heating/CoolingReturn) E]Othrr(explain under#21 Remarks) ft. S.:5'- f. U0
4.Date Well(s)Completed:.113 1?1 weilim M P-3 7s, 3 32 f" r,ra inp
Sa.Well Location: Phone # Zf 7--:U61 ft ft-
ft. ft
- 4&r_R,-)z �J-('XnnoA
Faoility/OwnerNam!e; Facility ID9(if applicable) ft. ft.
11�) 2 A" ft. ft.
Physical Address,City,and Zip WHAY ft if.
ix.RE
1A."o ..
- - a Aq-
county Parcel Identification No.M
5b.Latitude and longitude in degreeshminutes/secandi or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N 'XZ 4,(6 3 7 9,V - y - �
signatorl of Cmqcd Well Contractor Date.,
6.Is(arc)the weU(s): Permanent or OTemporary By signing thl.7fonn,]hereby certify that the wall(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or ^1) 5"v Y"( 15A NCAC 02C.0100 al-ISA ATCAC 02C-0200 WL11 Construction,Standards and that O'copy
Al If this Is a repair fill out brown well construction information and exp
lain the nature of the of this record has been provided to the well owner.
repair under f2l remarks section or on the back of this form. 23.Site diagram or additional},yell details:
You may use the back of this page to provide additional well construction info';
8.For Geoprobe/DIPT or Closed-Loop Geothermal Wells having the same (add'See Over in Remarks BOX).You may also attach add itioral pages if necessary.
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of'wells
drilled! 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths IJ different(example-3@200'and2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levbl below top of casing: (ft.) Information_Processing VA 1617 MSC,Raleigh,NC 27699-1617
if-water level Is above casing,use 11+
Control (IUC)
Injection wells. Copy to DWP,Underground 11.Borehole diameter: Bit Off- 24b.For(in.) InjectionProgram,1636 MSC,Releigb,NC 27699-163 6
12.Well construction method: AIR ROTARY thermal Return s;Copy to the
.24c,For Water1 Supply Open-Loop Geothermal
(i.e.auger,rotary,r able,direct pusb,'ctG.) county environmental health department ofthe county where installed'
FOR WATER SUPPLY WELLSONLY-. 24d.For Water Wells produeint aver 100 000 G.PD: Copy to DVJRi!CCPCUA
Pennit Program,l6ll MSC,Raleigh,NC27699-1611
13a".YieId(gpp) 1,0 Method.oftest: 6A, - .. 1 -1 .4 *ZN
70%HTH OZ DATE SITEVISITED:
Amount: -13
pxlic VISITED BY:
Form Gw-1 �tm Qiwity-,Division of Water Resources= Revised6-6-2018