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Home My WebLink AboutGW1--07703_Well Construction - GW1_20231122 v) :=w-grx CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Co?tractor Information: `J �nl��5�1�� l/Y� (//V - a4 WAr. `ZONES't:`'--:-::;,::._'.'�:1;_ ::::::"I -_____ • 7' WellContractor Name • FROM TO DESCRIPTION 0 ^ _ )4 , 90ft. Y 4 'PIAA_ NC Well Contractor Certification Number -_r°_ :15FOUT�R�(.ASING'(foi:'mufti=cased;Svelli):OR•I�NER:Crt;�ap'cable):�_=.. - Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS• MATERIAL 41 it t 11 ft 4:1 a.5 in' sD?-gi PU e_ CompanyName '•!•16iIlNNER:CASING:ORiTIIBING(geotliermalcloied=loop)::';'`.----..-- -- 2.Well Construction Permit#: PR Ali-2a2-3 O 3 1•3-3 ' FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(ke.UIC,Cow*,State,Variance,etc) R• ft in. 3.Well Use(check well use): ft it in. Water Sn 1 WeII: 57CR>� ,'_�. Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑�Municipal/Public ft ft ha. ❑Geothermal(Heating/Cooling Supply) grtcesidential Water Supply(single) ft ft ha. ❑lndustrial/Commercial ❑Residential Water Supply(shared) Ggovr.is: - - ._ _.._. ❑lrri lion ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft Q i ft rle.•t'�;�t,t ce o� t fi�cd. t' (PAt�- OMonitoring ❑Recovery ft. R! ft. Injection Well: ft ft ❑Aquifer Recharge .❑Groundwater Remediation -= 1_19.SANDIGRA.VRf.PACIC(if olip1 eilfi);: -- -. • ❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Test ❑StormwaterDrainage ft. ft • ❑Experimental Technology ❑Subsidence Control ft. ft. OGeothermal(Closed Loop) • OTracer ;7•20:33I1. fTGTAG(attachaddiiional 3eets:tii"necessaiI)_:_ ___.__ _ ___ _ _• FROM TO DESCRIPTION(color,hardness,soil/rock Vpe,groin size,etc.) ❑Geothermal(Heating/Co a ❑Other(explain under#21 Remarks) �i ft ft. S®r ( G��S� _Jr„� Date Well Started:x 6�� 12 V 70 /� 4.Date Well(s)Completed: P /2S Well ID# -8 9 L 30 ft- '�c, ft t e'y�'S 'gee (c 8,- . in.t e -y 5a.Well Location: Phone#::Z3�`73'.Y-70�� - ft gy ft. (' bc: k / Gamy- / f-I J _ kei'M .0 P• NE fti ft ,ad• ft. apt it LeLyed3, `i!4. ki 6K,. Facility/Owner Name Facility lD#(if applicable) ft. ft. • ft. 2.3R 13e&et, 124 �(k 1:., ft ft t ft. Physical Address,City,and Zip ;.2f:REMfA`REMAINS. - -� _-�.__._-.__._:_Nnl/ -9'--7 _7nn.1-')-.----•---`- UV`y ,,... Ad ...4LI+LJ County Parcel Identification No.(PIN) Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ... (if well field,one lat/long is sufficient) 22.Cer' cation: • jzi T g.3 N 2-6' IJs 3-2. w j. /1, �� GG-/4("t"a' Si o ealied Well Contractor Date 6.Is(are)the well(s): 1Ric'ermanent or OTemporary ,-- �we(k si ing thisfohn,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or triiTo 15 CAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out)mown well construction information and explain the nature ofthe 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 well details: • C 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 it- construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: I 24.SUBMITTAL INSTRUCTIONS VJ 9.Total well depth below land surface: (ff') Submit this GW-1 within 30 days of well completion per the following: d For multiple wells list all depths ifdifferent*ample-3Q200'and 2®100) .,'i. D 24a. For All Wells: Original form to Division of Water Resources (DWR), (� •10.Static water level below top of casing: l t/ (ff') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" • LC)7 24b•For Injection Wells: Copy to DWR,Underground Injection Control um11.Borehole diameter: (in.)�It Off: C t Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: Ail/ ls.•, e,1. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (i.e.auger,rotary,cable,direct push,etc.) ! county environmental health department of the county where installed _ C FOR WATER SUPPLY VEILS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA ft 13a.Yield(gpm) Method of test: t\ Permit Program,1611 MSC,Raleigh,NC 27699-1611 o hth Date Site Visited:N-A -23 /^J pPvvYl 13b.Disinfection type: 70�a th Amount: �`J Oz Site Visited By: Ella I e/hest,t',• •t., 4-freicd- u, no SAck 1 1Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018