GW1-2021-01024_Well Construction - GW1_20210305

WELL CONSTRUCTION RE C01W(gW-1) For Intelnai Use Only:
1
1.Well Contractor Information;
(Jc (/B O VW� 19'•PPATERZONE
Well Contractoxbame FROM TO DES_ TON
NC Well Contractor Certification Number ov ft. 6' 6
15.OUTER:CASING formulti�=cacsedivell3'ORLIPiER'ifa'licible',':..:''.:-_..
Yadkin Well Company Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name
43� .16.IMNDR"CASING 0R TUBING keo1)iem¢al closed to i =.
2.Well Construction Permit#:- FROM TO DIAMETER THICIMESS MATERIAL
List all applicable well construction permits(t.e.IlIC,County,State, mionce,etc.) ft• k/3s 1° �F t ✓G
3.Well Use(check well use): fG ft in.
Water Supply Well: FROM
REE TO E DIAMETR ... ._• SLOT SIZE THICKNESS MATERIAL
r Agricultural UMunicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) -ft. ft in.
IndustriaUCommercial Residential Water Supply(shared) -
•
Irrigation FROM TO I MATERIAL EMPLACRMENi'MEMO➢&AMOUNT
Non-Water Supply Well: O ft �' ft. -'e/T,
Monitoring [Recovery ft ft-
41 U'rt
Injecon Well: �— 1In-,3�u
ft. ft.
_AquifertiRecharge ©GroundwaterRemediation
'19:SAND V 'PACK if i-liable
Aquifer Storage and Recovery ©SaliIlty Banter FROM TO MATERIAL EMPLACEMEN•r METHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.'.D GLOG:attaclisdaitierielsheeGifnecessa'
C Geothermal(Heating/Cooling Coolin Return Other FROM TO DESCRIPTION(color,hardness,soil/rock type,arain size,etc
(H g/ 1g ) (explain #21 Rem(a�rks) ft ft G, 1 4 M v�
4.Date Wells)Completed: /"��J �/ WeIIID#/"Ytfi� — "/� -7 ft 5-70ft. ^7 /_/;41� L•• X4-
G"
Sa.Well Location: Phone number ia�- 30,2- JIgi
ft ft
�t'9�G35 .a �11y��1ltAt�v S�t4�,, ft ft - --�
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. �_-�• "��"'
ft. ft
Vt v Physical Address,City,and 2Yp ft. ft Ivl �:
21:REMAPM'
r y/Z
,l"e�
Identification
County Parcel Ide ,(P"
btad�S i�."•:1.J1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3s° S�, 05' N l�$b` 7� �, 7 w
6.Is(are)the well(s) Permanent or Temporary Sigma .f Crdida Well Contactor Date
KKplin
By signing thisfarm,1 hereby certfir that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: rJYes oro with 15ANCAC 02C.OJ00 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis is arepair,fill out known well construction information the nature of ilie copy of this record has been provided to the well owner.
repair under P21 remarks section or or the back of this form.
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 site details or well
construction,only 1 Gw-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: �.s� 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(a)200'and2Qa 100D construction to the following:
10.Static Ir'ater level below to of casing- ?
P g' � (fi'•) Division of water Resources,Information Processing Unit,
Ifwaterlevel.s above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Offlp•�1 b 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this�foim within 30 days of completion of well
12,Well construction method: (A I r (' b 1 construction to the following:
(ie.anger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) YL Method of test: f Q 1 1' 24c.For Water Supply&Iniectioli Wells: In addition to sending the form 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 construction to the county health department of the county
where constructed
FoIM GW-1 North Carolina Department of Fnviranmental Quality-Division of Water Resources Revised 2-22-2016
Date site Visited I -) bye ,emu - ta3e - be, tJy
r
l

/ a COMPLETE IP INIMICE GOES TO BUILDER
OWNERS NAME: �/��R�J � l-�o Lk^ BUILDERS NAME:
ADDRESS: �(��� S'�oa�vv� s L� ADDRESS:
PHONE# OFFICE#
CELL#
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Well Construction Permit For Office Use Only
Davie County Health Department
q 210 Hospital Street *CDP File Number 290434
P.O. Box 848 PIN Number:
- Mocksville NC 27028 Tax Lot#: i Tax Block#:
Phone: [phone] Fax: [phone] Evaluated I For: WELL
G
PERMIT VALID UNTIL: 7/9/2025
Property Owner: Gerardo & Mary Russell Applicant: Thomas &Whitney Shoun
Address: 8025 Broad Street Address: 1085 Mystic Lane
City: Rural Hall City: King
State/Zip: NC 27045 State/Zip: NC 27021
Phone#: Phone#: [phone]
ProoerW Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:
Road "Proposed use of Well:
le NC 27028
If Other'
Latitude
Longitude Directions
Site Address: Wagner Road Directions:601
TL on Ijames Church Road
TR on Wagner
less than one-fourth mile sign on right
Well Contractor Information
Drilling Contractor Driller Registration
Permit Conditions
*Permit Conditions
Well must be: ftm�
*Permit
least 50'from any part of septic including Tank and Repair area 382
-at least 26 from any building foundation including decks
-out of any drainage ways
li
Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of
the Local Health Department.The permit may be revoked at any time for failure to comply with existing regulations.The siting of approved well construction
area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be
changed without permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the Health
Department.
*Issued By: 2366-Na r, Emil 0=3 *Date of Issue; �., , 0 , 9 , , 1, ® , a, 0
Authorized State Agent.
Hand DraWmg O Import Drawing
Owner/Applicant Signature: **Site Plan,/Drawing attached.**
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i#V-616%A0110 a nv%®®1%J11 f-�re�9�- 2904;34
4 Davie County Health Department CDP File Number:
210 Hospital Street
County File Number:
P.O. Box 848
Mocksville NC 27028 Date: ® 7 / 0 9 / 2 ® a
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Drawing Type: Well Permit Scale: , 1. . O Block 6
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