GW1-2023-00758_Well Construction - GW1_20230112

"eIRIfJC21I0N RECORD (G'v-V-1) For Internal Use Only:
:'1:Well Contractor Information:
3e«Y 14.WATER ZONE S
Well Contractor Name FROM TO DESCRIPTION �.
rr ft ft 1/
J (� ft. ft L
NC Well Contractor Certification Number 15,OUTER CASII G forrriulfi-cased wells OL11 R if a Ucable
YADKIN WELL COMPANY,INC. FROM To DIAMETER THICKNEss MATHaIA•
ft, ft in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: I-A FROM TO I DIAMETER THICIINESS MATERIAL
List all applicable well construction permr s(ae. County,State,Variance,etc) ft ' ft ? in. as Q be.jr- Meet
3.Well Use(check well use): ft ft' in.
Water Su Well: 17.SCREEN
Supply FROM TO DIAMETER SLOT SIZE TECICICKESS MATERIAL
❑Agricultural ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single). ft it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � ft ftFoT v QOunra@ 1:5 b
®-
[]Monitoring ❑Recovery it ft. 5S
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/CooliugRetum) ❑Other(explain under421 Remadcs) FROM To DEscxteTloN eotaa bar taws,zo v,ocx Zia s;u ern
S ft.
4.Date Wells)Com Meted: 3® 1� Well ID# 7,0 1 Z's ft 1-' _ft'
5a.WellLocation:(�°�eay) Phone #o� -7
Fa 'ty/OwnerNarae FacilrtyID (ifapplicable ^�-'v :, ft' jAN -
® ft.' ft. L.i j
ft. ft
Pbysical Address,City,and zi/ - -_
i
21.REMARKS ,°':..-'•�i'
County Parcel Identification No.CKN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one brttloagis sufficient) 22.Certificktion:
6.Is(are)the well(s): Permanent or ❑Temporary Sigoato cfCmpedWeH Contractor Date
By signing thisfarm,l hereby certify that thewell(s)was(were)constructed in accordance with
7.Is,this a repair to an existing well: Oyes or IPOO 15ANCAC 02C.0100 or 15ANCAC 02C.0200 WL-11 Construction SYandardr and that a copy
If this is a repair,fdl out known well construction lnfarmallon and explain the nature of the of this record has been provided to the well ow{per.
repair under f2l remarks section or on the back ofthisform.`
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction infd
construction,only 1 OW-1 is neyeded, Indicate TOTAL NUMBER of wells (add See Over'in Remarlcs Box).You may also attach additional pages if necessary.
drilled: / 24,SUBMITTAL INSTRUCTIONS i
9.Total well depth below land surface: Submit this GW-1 within 30,days of well completion per the following:
For multiple wells Iist all depths if dierent(example-3 c200'and 2©100)
�-® (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levO below top of casing: ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 '
lfwater level is above casing,use"+"
11.Borehole diameter (in.) BIt Off: _ 24b.For Iniection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health department ofthe county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Xield(gpm)
I Z Method of test: ®o�S Permit Program,1611 MSC,Raleigh,NC 27699-1611
�i
OZ : ��� ?
13b.Disinfection type: 70%HTH DATE SITE VISITED
_Amount: _
rITED BY: 9
c
11*",m iW C3WP-1 ality-Divisienof Water Resnurces Revicrdfi_fi_90rR I
d
�.'� Fn