GW1-2021-01463_Well Construction - GW1_20210305

CONSTRUCTION ,�• 1 WELL CONSTRUCTION RECORD(C®][8D(GW-11) gg � � For Internal Use Only:
I.Wall Contractor Information:
_ J OA C— 60­� :1a`WAt'�R2OATES' .
Well CoutractorName t -FROM TO DESCRIPTION
1
NC Well Contractor Certification Number -(v J
•'• :, °'' � -15.OD'1'ER:C.�_SISIC-formvl&=ca'sedi' "ORLINER'rf u�licaTile'':.•:'--:--.
Yadkin Well Company Inca FROM TO Drenntrrrn THICI°VEss MATERIAL
Company Name
ft ft
.16.ILT1VER ASIIIGORTUBr1!1C eot5e a1rinsedIcn ^>- _. :•
2.Well Construction Permit#:. �( r/�/ FAOM To DrAntiTm THICIQVLss Marar.
List all applicable well construction permits ri.e.MC,Co.'*state,Yanionce,etc.) ft ft 6 r in.
3.Well Use(check well use): ft ft V c � C�
FROM TO .:MAMIErr.•. ... ... __.•..;: ...., ..
[Geothermal
ply Well: 17:SCREEN: :.. _..•:-,._..
R.. SLOTSME• THICKNESS MATERrAS
ral �MrmicipaUPublic p ft, ft m
(Ileating/CoolingSuppty) Wesidential Water Supply(single) ft in/Commercial Residential Water Supply(shared)
TO W-TER'tar. EMPLAt ENONTMETHOD&AMOUNTon-Water supply Well: ft ft.
t►n I `�c Cam, s �� -S
C Monitoring Recovery rt •`Q j `:� Ce t�C S'l�a.ter d
Injection Well: C 'S
ft. ft
-:'?Aquifer Recharge [C)GroundwaterRemediation
_'Aquifer Storage and Recovery [S Barrier I9:SAND/GRAVF,i.PA-CK rFa',•plic2bl`e ' :. . •- �•
a1laIty FROM TO MATERIAL, jEWLACEMMNTrW=OD ..
_Aquifer Test MStormwaterDraiaage ft ft
Experimental Technology Subsidence Control ft tt
Geothermal(ClosedLoop) OTracer 2o.'DRff_mqZ,OG`attaeliaaaiticnelsheetsifneces5"- _
Geothermal(Heaiing/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(gym,varaaess,soa"vrack a ae etc
y g� 12 ft 1 d ft
4.Date Well(s)Completed: / Well m# O Y 3,J 0 2 ft �� if M e.:
Sa.Well Location: Phone number .J�'-q3Z e 7 7 7�) 20 ft ft to 1�7 ' a t tan )16
�7%J.Jar✓ �I ti!`�t^��" V ft S U ft' s�v9 t' 7�`t ,'el
Facility(OwnerName Fae M#( applicable) Sft
ahH1S�
.�1c
ft fr. ✓
Physical Address,City,and Zip ft. ft
Zl•REMA_RTSS.' .
11-c ts . .
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/secoadb or decimal degrees:
(ifwell field,one lattiongiiss sufficient) ,l {� 22.Certification: 6 j
3�15 —� i /- N �( 4 ®� , d" Yet
6.1s(are)the well(s)iWermament or MTemporary Sipature of Certified Well Contractor Date
� By signing this form,1 hereby certify thdt the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or tL�K with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill out Imawn well construction in fonmtian and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional vrell'details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells.having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is yneeded. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: { SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: "y
(ft-) 24a. For AlI Wells: Submit this form within 30 days of completion of 1ve11
For multiple wells list all depths ifdifjerertt(example-3@200'and2@l//OgD construction t0 the following:
10.
f Static water level below fop of casing:
If Division or"Water Resources,Information Processing Unit,
waterlevel is above casing,use"+" / i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) git Off tl d Q� „C 24b.For Iniection Wells: hi addition to sending the form to the address in 24a
ii -- above,also submit one copy of this;form within 30 days of completion of well
12.Well construction method: A l r �w1�l r i/ construction to the following
(ie.anger,rotary,cable,directpusk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY[WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: A t 24c.For Water Sunnly&Injection Wells: In addition to sending the Than to
the address(es) above, also submit one copy'of this form within 30 days of
13b.Disinfection type: HTH Amount CUPS completion of well conshucfion to the(county health department of the county
where constructed
�s .
FDrmGVd-1 North Carolina Department of Environmental Quality-DiiviisssiionofWaterResources laai Retdsed2-22-2016
mate Site Visit

1
OWNERS NAME: tt-e / BUILDERS NAME:
ADDRESS: Co � 1 S (A�G�r i ci e.Vl R ADDRESS:
PI-lOIVE#
- , OFFICE#
,�G$ U' '� �d �ElL#
Cal (COMPLETE IF INVOICE IS BILLED TO
'"
�- Je 'VContractor
Ac4i
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VVCH-VUP-20 1 t)
WtLKES COUNTY HEALTH DEPARTMENT
Environmental Health Services i
306 College Street,Wilkesboro,NC 28697 Phone [phone]
WELL CONSTRICTION PERMIT W
This permit shall he valid for no longer than 5 years from date issued. .,.
Owner:_ r1. `7r EelEk Type of Well
Parcel# I�-038aS Total Well Depth: Feet
Type of Application: New 0 Repair lJ Type of Casing:
Casing Depth: _ ! Feet
Abandonment U New/Replacement❑ Type of Grout: �.
Directions to Property:__— Grout Depth: Feet
-----.SCU BACK Method of Groutin
Yield: GPPIr
Static Water Level: Feet
Subdivision: Contractor/Driller Company:'
Section: _ Lot: _
Attachment regarding well abandonment: Yes fV Individual Driller and Certification Number:
Type of facility this well is to serve: _ _ _
Hot'cs'E Septic system permit number far thi proper s ty: i:zq:0
Properties this well is to serve; t o3ugf' Date septic system installed on this property:
Date Issued: ^ 20 EHS: / f�� `
Date Grout Inspected: EHS:
Certification of Completion Date: —�_ — ENS:
Date Water Sample Collected: _ _-.- EHS: _
i
Received by Owner/Agent:. s O- -l 9 Date:
As a condition 4f the._per-T fhe®avner and/or ap Ip;cant must maintain the retere pe pointt �d_e_signate l an.the
site p[an,leyou€until the«!ell is inst ft d.ar tfie_Agrtn t haq_explred.
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