GW1-2023-00759_Well Construction - GW1_20230112

-&,b4C�I`�1'S TRTJCT1IDN RE CIORD(G J�I-1) For Internal Use Only:
L Well Contractor information: I�
,�i�y wQ1�rc•'15 14.WATERZONE-S
F— FROM TO DESCRIPTION
Well Contractor Name ft. / 6 fr. '
Ls e " �
1?45:�A ft. 3M ft ! GP�n
NC Well Contactor CectiScation Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
YADKIN WELL COMPANY,INC. FROM To DIAMETER TMCKNESS MATERIAL
$, ft
Company Name 16.INNER CASING OR TUBING eotherma]closed 100
2.WellCOnstrucdOnPermit#: ®' FROM TO DIANIETER THICCNMS MATERIAL
List all applicable well construction permits(ce UIC,Coun7Y,State,Yariance,eta.) fl- it &$eI in. p
3.Well Use(cheekwell use): ft ft. in.
Water Supply Well: 17:SCREEN
TO DIAMETER SLOT SIZE THICIfIVESS MATERIAL
❑ ❑ al/P
Agricultural Munioipublic ft. ft. in•
❑Geotherm FROnSal(Heating/COoling Supply) Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 111.GROUT
[]Irrigation ❑Wells>100,000 GPD FROM TO +MATERLU, EMPLACEMENT ATE, &AMOUNT
Non Water Supply Well: d ft' ':) ft' i01-e P 4 Qo v eJ 12 to 4,5,%
❑Monitoring ❑Recovery it %
Injection Well: H. %
❑Aquifer Recharge ❑Groundwater Remediation
19.SANA/GRAYEI.PACK da livable) �
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑hxperimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLOG attach additional sheetsifnecessa
❑ rm Geotheal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,snillmcktyp4 gmin aim,etc
Q ® ft. ft. ®Q
4.Date Wel(s)Completed: f 7 Well ID#doff4� 6 S� ft' '�7 ft' �j(`qyi,a VC
ft. fL
Sa.Well Location: Phone #
Facility/Owner-Name Facility INCifapplicable) ft' ft'
�
ft. a Y•�,�:^"r 'F ,'Igo d'._,�i
n fl�t�Bd' ft AN n
z2823-
Physical Address,City,and Zip
t.
21.RAMARKR
County Parcel Identification No_(KM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield one lat/longisspu�fficient) ® 22.Certification.
.A!t!0
6.Is(are)the well(s): (Permanent or ❑Temporary Sign ore of CAtifirdWrIl Contactor Date
By signing thisfonn,I hereby cero that the wells.)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or AND ' • 15AN34C 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
]f this is a repair,fdl out known well construction information and arplah7 the nature of the of this record has been provided to the well owner.
repairunder*21 remarkssedion aron'ihe backofthisform. 23.Site diagram or additional Well details
S.For Geo robe/DPT or Closed--too Geothermal Wells having the same You may use the back of thus page to provide additional well construction info
(add'See Over'in Remarl�Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 c)D (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tf dierent(example-3@200'and 2Q100)
�® Ma. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" u
11.Borehole diameter (in.) Bit Off: G e oa 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUQ
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY 24c.For Water Supply and Open-Loop Geothermal Return WelIs:_Copy to the
(Le.auger,rotary,cable,direct push,etc.) 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,1611 MSC,Raleigh,NC 27699-1611
I3a.Xield(gpm) 2 Method of test: �
e OZ DATE SITE VISITED: _
136.Disinfection type: 70%HTH Amount:
.I — --- -- —I VISITED BY:
anmental.0uality-Divi.cinn of WatrrR r_cnnrrrc
RP��P l fi_r_�ma