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Home My WebLink AboutGW1-2022-00008_Well Construction - GW1_20221216 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: k i Joseph Bade , p Y Well Contractor Name FROM TO DESCRIPTIO 3271-A I n_(+ ry ft. f[ NC OWell Contractor Certification Number D P L I �` 202! a fig;{yUxl R,GgS1NG for_niniff cased;Xvelis B&K Well Drilling Inc FROM TO DIAMETER THICKNESS MATERIAL t,Mrf. x,��,�:..y,,.;l 0 ft. I„�'t ft. 6 112 m. SDR-21 PVC Company Name r;tg°r 1:iv; �[^1J ' i�lb:�i14'NER G*ASINGOB'I'UB1NG '"otTi�ermal closed=l X, ""�, � ... "§ r'i�1 aoa .. s' . ATE 2.Well Construction Permit#: t� � �J!�r FROM To DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,[Variance,etc.) ft. ft. in. 3.Well Use(check well use): f[. ft. in. ; , Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural [3Munici a Public, ft• ft. in. Geothermal(Heating/Cooling Supply) srdential Water Supply(single) ft, ft. in. Industrial/Commercial DResidential Water Supply(shared) i i ,,,,]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD 8c AMOUNT„ Non-Water Supply Well: "' fL Monitoring E)Recovery ft, ft, Lj Injection Well: ft. ft Aquifer Recharge DGroundwater Rcmediation '.>19 SAND1GRAVEI'PtYCFC tf'a' file's A W. .... ,« y f s;..< „taw Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test [3Stomrwater Drainage ft. ft, Experimental Technology Subsidence Control ft. ft. Geothermal(Closed Loop) OTracer =20:DR117s1NG LOGi'attaeladdruiia"sl"sheets lE"reecessrrry Geothermal(Heatin Coolin Return) 0 Other(explain under#21 Remarks) FROMI TO DESCRIPTION(color,hardness,soiurvelr type rain size,etc. 4.Date Well(s)Completed: J Well ID# f} f[ (} R' 5a.Well Lo-cation: y- ft. D It- IL —+ e 1676,117 v r /'ram— Facility/Ow er Name Facility ID#(if applicable) ft. ft. f 1 R/ i/ �t' orlfl/ ft. Oq ft. Physical Address,City,and Zip ft. it. County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one)at/long is sufficient) 22.Certifica N W 6.Is(are)the well(s) Permanent orTemparary Signal c of C ific welt Co Ira at �� $y gning this form,t hereb rtrfy that the wells}was(were)constructed in accordance 7.Is this a repair to an existing well: OYes or El�j"' w1 15A NCAC 02C.0100 o SA NCAC 02C.0200 Well Construction Standards and that a f this is a repair,fill out known well construction information and explain the nature of the ct of this record has been provided to the well owner. repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details: 8.For Geoprobe/1)PT 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled: SUBMITTAL.INSTRUCTIONS 9.Total well depth below land surface: V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following: 10.Static water level below top of casing:40 (ft.) Division of Water Resources;Information Processing Unit, V'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 1/8 i 11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a Air Rotary above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY., 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 110 Method of test: !y �r / 24c.For Water SuDDIv&Iniection Wells: In addition to sending the form to the address(es) above, also submit one,copy of this form within 30 days of Chlor Tabs 1 1/2 Lbs completion of well construction to the coup health department of the 13b.Disinfection type: Amount: F I �' F county where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 s ICHD Environmental` Health Division INSPECTIONS:704-664-3703 Statesville Office:(704)878Z305x3456-Mooresville office:(7o4)66o-3625 c5W Y xazz PRIVATE DRINKING"WATER WELL PERMIT# i5 5 PIN# t_1 S t t�z - 41 05 Type of Permit Ldrele one) New Repair Abandonment APPLICANT/OWNER N E: c Bra trs 11. ADDRESS. 11G NC. 2 (D PHONE:_-X4--50a-SSix+ DIRECTIONSTOSITE:�NC-.i QS`1"t�ICI� tlPylil"+=1 We,?Akr_Nd 3S 1 SITEADDRESS: 341 r'Cl,-Routhc: -Zs iU.ko SUBDIVISION: : . � SECTION/LOT: "—/ - 7 � tnitiahs[te Sketch CALL, _66370 3 for 4- Grout or Well'lead lnspectroris �� Between 8 9arro .- GROUTING RESULTS Total Depth �`-^�.,_ Depth of Casing Yield a Notes: � f 'jn i C4 �r: CC - - - )O GPm - PERMIT CONDITIONS/COMMENTS: r'Oflt,w c,li n1C tintQ.11 V1J1ks. �ri ii i�1Sjr 0 e�lell ChYQc� WELL PERMIT ISSUED BY: DATE:el-Zj-2.2- (Permit is.valid for 5 years from date issued.This permit may be revoked if it is determined there has been a material change in anyfact or''cumstan upon which the permit is issued. Actions of the employees of the Iredell County Health Department shall in noway be taken as a guarantee that this well will produce water of any particular quantity,or quality orfor any amount of time. Employees of the Iredd County Health Department assume no liabilityfor any damages,either director consequential which maybecaused by this well.) Well Contractor: CONTRACTOR CERT#t: GROUT INSPECTION BY: DATE: OR CERTIFICATION OF GROUT NOTWITNESSED BY DEPT: DATE: WELLHEAD INSPECTION BY: DATE: WELLHEAD INSPECTION(check when completed): 'GROUT TO GROUND SURFACE❑ WELL CONTRACTOR ID PLATE❑ PUMP INSTALLER ID PLATE❑ SAMPLE PORT❑ ACCESS PORT/VENT 0 WELL SEAL❑ WELL HEAD 121NCHES/PITLESS ADAPTOR 8 INCHES ABOVE GRADE O CERTIFICATE.OFCOMPLEriON BY: DATE: WATER SAMPLES BY: DATE: Attachments:Form GIN-1a(reouired.exceot for abandonment)❑ Form GW-30 O Water Sample Results❑ Plat❑'GALL 7O4'6B4 3TQ3 to schedule ,duI:6 w 11 head rrtspections between 8 9am