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HomeMy WebLinkAboutGW1--05186_Well Construction - GW1_20230814 Wi JL CiINSTRUCTIICN RECORD (GWV-L For Internal Use Only: (.Well Contractor ilnf a'tion: 14.WATER ZONES FROM TO DESCRTTION Well Contractor Name j a`e ft. 1)3 ft. 3 &' ' f 12ei 5 to S-/�- `) F),ft. I93 ft C)d� diet NC W Contractor Certification Number 15.OUTER CASING(for Multi-cased wells)OR LINER(if a licable) YADKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL ft ft. in. Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Permit#: 3 U g , 2 e FROM TO DIAMETER TH1cIINESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 4•I ft l_ l_ ft l.fJ 6 in. Yj, %� SPP a 1 . 3.Well Use(cbeck well use): ft. _ ft. in. "� 1 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL DAgricultural ❑Municipal/Public ft. ft. in. _ ❑Geotiiermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. O' ❑Industrial/Commercial . ❑Residential Water Supply(shared) 18.GROUT ❑in-Igation ❑Wells>100,000 GPD FROM TO MATERIAL (� I EMPLACEMENT METHOD&AMOUNT D Non-Water Supply Well: ft. ft awl Chi rewii7 , ❑Monitoring ❑Recovery ft ft. Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Test ❑Stormwater Drainage ft. ft. jt ❑Experimental Technology ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION{color,hardness,,slUroekrYP4 Brain sae,etc.) 7 a 9',7),j 0 ft. () ft. .Sit r 4.Date Well(s)Completed: Well INP-5lt al ftft" 6ei' 1�l-C NC c 5a.Well Location: Phone # 334-.�g.2-.1.�a ft. 11. ft /1 d AlL ilk t J1.-2-ice.- 79 ft. 173 ft 5O-R. Oo lit )1/4-0C S Fac 'ty/Owner Name Facility ID#(if applicable) l 13 ft' 39N ft 50 f�- j7 5 1-Iv! i r-& i d rtt®/t t� N._ F ft. ft. 'I l Z`� Physical Address,city,and Zip a A�of q' ft. ft. U n. 'e a 7'":."a 4,'"l 21.REMARKStlKS '"i^I�I-�+-,r t4 .i tY E r" County Parcel Identifi cation No.(PIN) Wit�^'� �#" AUG G 1 -: z LJ A 44 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ir'� r. : ^n �,�,, ,. I tD (if well fold,one 1at/long is sufficient) 1/ 22.Cert ification: .3 3 4, 1.2,22 C 4 N c i 14�P! 4•2® 9 W CSI,-r` :8, :a 6.Is(are)the well(s): Ofermanent or ❑Temporary Signature of Certified We acror Date By signing thisform,I hereby certy5,that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: DYes or o 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy Ifthis is a repair,fill out known well construction information d explain the nature of the of this record has been provided to the well owner. repair under#21 remarks section or on the bock of thislform. 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 GW-11 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: �f 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 30�^ (ft') Submit this GW-1 within 30 days of well completion perthe following: For multiple wells list all depths if different(example-3Q200'and 2Q100) 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: Li5 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 lfwater level is above casing use"+" 11.Borehole diameter: 'rP (in.) Bit Off: a / 6 24b.For Injection Wells: Copy to DWR,Underground Injection Control (IUC) Program,1636 MSC,Raleigh,NC 27699-1636 km AIR ROTARY 12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 6 (Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed `', FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWI?,CCPCUA t Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) Method of test: Cdd a 0 a V 13b.Disinfection type: 70%HTH Amount: IC) OZ DATE SITE VISITED: f `�1)-"2- 1t a ISITED BY: !l� Prire�a - 64 FormGW-1 I ental Quality-Division of Water Resources Revised 6-6-2018