HomeMy WebLinkAboutGW1-2021-01469_Well Construction - GW1_20210305 k
WELL CONSTRUCTION CTlION RJEC RD(9W-11, t For IiAemz Use
1.Well Contricto lirformation:
Well Contractor Name
NC Well Contractor CertiScationNumber
t.•� ;,r•' '15.4117'I'�s±,�:K.h�Zt:(fm�v�lti�ca'sed-rfrlTs'ORr�+R rffa "'caul
FROM TO DiA.i7.'1E1':LP, M11M Sss MAT Tar !
Yadkin Well Company In&;�` �'�A,•''�
CompanyNarne ,,.¢1.k'�ti,'„•' • •,16rsI "�'�'uSttz4??TiT��+T�{oeo�st�atcInYed-Iari :: :.•=;':--'�. :• :.
2.Well Construction Permit#_ FROM TO A_T@SV=- R TMCI NMS MA'�'Rrar• I
PF F r 0: ��_ > Pa.
Sistalia liaableivelTeorrstruerion ernrRs r.e.IIIG;Coup State,Yoriance,etc E
3.Well Use(check well use):
Water Supply well: : ._ r.•... ': =... a
FRon? To sioxsM• I•xale>EavFss I
LGrioultu al nMunicipal/Publicothermal(Ileating/Cooling Supply) Residential Water Supply(single)ustriallCommezcialbResidentil Water Supply(shared)
gdtiOD FRQ.iYI I TO 1s=sTE A...� -I s' .IgA ni.fti2n2fi'T�03) �iUD ' I
7—Non-water Supply`'•Jell: f` _`. f�'it "e''' g. prCA p � y' „�'4
__monitoring oRecovery ft. U � n .� LY b
Injection}�ilelL tt.� ��; �e�a�r�
A uifer Recharge OGroundHai�rRemediation fe.
- f
i;SAYM/t'I-EM 'L"A' r S e nle}
Aquifer Storage and Recovery [iSadnityBarrier our TO rrAITI ._ '_aCM03114rlu`irs'so_ !
Aquifer Test OStormwaterDrainage fC
Experimental Technology nSubsidence Control ="t ft
C Geothermal(Closed Loop) OTzacer 2 0..D3t=rqGL0 G.Titfg i il3iiicnal sh&,ifneccssarfj.,
C Geothermal(Heating/CoolingReturr) ("Other(.Tlainnndw#21Ronan.) 3rR4TM xG �zsc x?ar �r9rtaran >suvr x e� .Lc7 _i
46Date Well(s)Completed: I>,.Li-& k well ID#- 0 —30� �� ittm ed
5a.Well Location: Phone number�g����� �� �'�� f� f4 Gayaace_��p�� _I
ft
vw Facility/Orvnetrl ame ft
FaciilityM4(iffgplicable) ft' j
�a Physical Mdress,mill,and Zip t ft
I
31..
Cotmti PmralIdentitieationNo.(Pllq) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 4 � ��g�g� pC"� f -
(ifwellEald,one latRongissnffrcrirnt) ® 7-7.Certification:
x S N .5 xc Pre r- Ftj
6.Is(are)the well(s) Pernanent or OTemporary Signature of Certified Well Contractor Date
By sio fig this fiom,1 heraby cesr5,that the Hell(_)was(were)wostrreted ir,accw va>;r:
7.Is this a regain to an eszsting well: Yes or i�To with 15t1 NCAC 02C.0100 or I5A RrCAC 02C-0209 FtWI Cons mctioi Standards a<d Rn:
If this is a repair,fill aut ImoHu i^ell constriction information iWd explain the nature ofrhe copy ofihis record has beer,proWded to the welt owner
i
repair•under 421 remarks section or on the back ojthisfarm. 7 i3 ! 1 `-
., Site d;sgram:,r ad_.6mr._wa -er.
g.For Geaprobe/DPT or Closed-Loop Geothermal Fells having the same You may use the hauls of t ris pago io pro,•ide additional tiuell site detain or
construction,only i OW-1 is needed. Indicate TOTALNTtIAMER-ofwsIls construction details. You may also attach additional pages if necessary.
drilled:
9.Total wall depth below land surface: ( ) 24a. For All Wells. S01 mit this`;f¢tr0 Turin 30 days of completion oi
For multiple wells list all depths ifdYjorrit(ezample-3@_7 00'and 2 n(,"1700)
construction to the i-ollovdne:
10.Static water level bellow top of casing: 5 m 01M) Division of 1�i ate_Resc°arc,,la formation Esoeessing ETDir
IfH'aterlevel is above casing use"+" tom. 1617 hrap Service Cuter,A:aleigh,NC 27699-36-7
1I.13orehole diameter: f (in.) Bit Qffa l 24h-.For iierNon wells; Yr,addition to sending the form to the address in=-t.
above,also submit one copy of ibis`fo,-m)Athin 3D days of completion of yvcp
12,Well construction method: e. construction to the f0cming:
(i-e,auger,rotary,cable,directpusk etc.)
Division ofWaerResources,Underground Injection Control Program;
[13b.
R WATER SUPPLY WELLS ONLY: 1636 Dail Be:-,rice n enies,Raleigh,NC 276994636
a.Yield(gpm)_ __ 1Ylethod of test: el�. 24c.For Water Snr;uiv&hiiectioti lhrehs: ID addition to sending the mrm if
the address(es) above, also submit {one copy of this form -dthin 30 days of
Disinfection type: HTH Amount± GNPs i completion of r,.11 construction in the county health department of the count
where constructed-
All
AL:-.-
Form GW l North Carolina Department ofHuvixomnen 3u
tat L alzry-Ln+�rsran o?5°:'aYaF t'<;r,<
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ERS NADWE
WILDERS HANIE:
k9DRESS. ADDRESS-
OINE OFFICE
CELL#
COMPLETE IF INVOICE IS BILLED TO
Contractor
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ECM/2020/TUE 08: 24 AM Yadkin Cty Permits FAX No. 336-849-7925 P, 0011001
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YADKIN cou.�TY .
wc., iF.YI.hF YADKIN COUNTY ENVIRONMENTAL HEALTH
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t
WELL,LOCATION
14-082 JWCo.
APPLICANT/
OWNER -J-( C PERMIT#\� ZOFS �� �c77�1�^ :O DATE: I�(,'d" t�
ADDRESS A!e
WELL INFO V<EW WELL o REPLACEMENT WELL M//WELL FOR.SINGLE RESIDENCE
o WELL FOR 2 OR MORE RESIDENCES o PRIVATE WELL o PU BLIC WELL
(Not to Scale)
CZ
05 3 r
65
PIP
Comments:
Name,RAH #� a e ! Authorized State Agent
i