GW1-2023-01809_Well Construction - GW1_20230223

�r `".QNS TRUCTION RECORD (GW-1) For Internal Use Only:
,ontractor Information: _
14.WATER ZONES
FROM TO DFSCWTTION
Wcil Contractor Name 1 S
ft, ft. alki-4 clilr-
WS
NC Well Contractor Certification Number is.OUTER CASWG formulti-tarsal wells OR LINER if a licahle
YADKIN WELL COMPANY,INC. FROM To DIAMErES1 rffic[flvEss MATERIAI
ft. ft. in.
Company Name —
16.INNER CASING OR TUBING geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMEYER THICIO•IESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fG it in. j, t&,A t ?
3.Well Use(check well use): ia.
Water Supply Well: FR SCREEN _
17tOM TO ETE:d DIAM _ SLOT SIZE THICIQVESs MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, i o•
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it,
ClIndus rial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERAA.L EMPLACEMENT METHOD AMOUNT
Non-Water Supply Well: o, ft' ft' y1.1;04n Arc-v "j "' L
ii if
[Monitoring ❑Recovery ft. ft.
Injection Well: —
❑Aquifer Recharge ❑Groundwater Remediation —
I9.SAND/GRAYELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To . MATE AIL EMPLACEME ENTMTam
❑Aquifer Test ❑Stormwater Drainage ft. ft. —
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Coolmg Retmm) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness.soittrork a aw rim etc
C ft 't l 4- CJ/C'VC 1
C
4.Date Well ID
s)Completed:a�� Well # 1'__ ( %Vft. _
5a.Well Location, Phone # k1 60),- C) ft. (9() ft.
Fac /Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip 1�
gg 21.REMARKS
County Parcel Identification No.(PIls') —
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees: —
(if well field,one lat/longis sufficient) 22.Certificatio
6.Is(are)the well(s): Crermancnt or ❑Temporary ignature of Certifi—C776TContractor Date
By signing thisform,l hereby certify that the wells)was(were)constructed in accordance with
7.h this a repair to an existing well: ❑Yes or *0 15ANC4C 02C.0100 or 13A NCAC 92C.0200 1f'ell 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(o Ihr well owner.
repairvmder ti21 remarks section or on the back of thisform. 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 info
construction,only 1 QW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 2 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fio) -(ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3©200'and 2©100D
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (ft.) Information Processing Unlit 1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
Bit Off: 19'f�J 24b.For Inieefron Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: l; (in•) 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 depirrtment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producirg_over 100,000 GPD: Copy to DWR,CCPCUA
0� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) a,(, � Method of test: ,Q'/,f' -�;
13b.Disinfection type: Amount:
70%HTH DATE SITE VISITED: ��v
�� Oz
Psir-ee --
---.__.------- -- VISITED BY:
Form GW-1 onmental Ouality-Divisinn of Wa}nrR"niir—