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Home My WebLink AboutGW1--01668_Well Construction - GW1_20240313 / CD WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Con 1tractor Informttion: .,d e-iiryt �-' —c,\'1ct t;14 WATE -7.oNES.`:` ;...::�_z. ?l'.;:7r,7c. _ ... _:.y .'!� '"H_:.....-., -...<:.t Well Contractor Name FROM TO •• DESCRIPTION tZs • 13° gYaft Si (Puy I. NC Well Contractor Certification Number ;tIS:'OD CASING(fncmultVerised:wells):oR'T1TER,(ifa 11calle)2 _ '::^�'__ Yadkin.Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL �q ft. ft in. f°' CompanyName k r �._ _, 'is.6 301Ei2 CAS NG:OR::T finNatke itliesmiil rloseTlSop)=-�� `_ `.�•. 2.Well Construction Permit#: - 3 t- tJ q1 FROM TO • DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) + 1 ft, e,i ) ft L/ `1Cf in. 51)R, 1 P,0 C 3.Well Use(check well use): 6 ft ft Q in. FasiWater Supply Well FRO 4I TOE DIAMETER- SLOT SIZE THICKNESS THICK ESS MATERIAL ❑Agricultural ❑Municipal/Public ft ft. in- P. OGeothernial(Heating/Cooling Supply) ,Residential Water Supply(single) ft ft in. 27 ❑Industrial/Commercial ❑Residential Water Supply(shared) - -_ ❑hrigation ❑Welis>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT -- Non-Water Supply Well: ,1 ft' 2 ft hilokPl. Pot! EL, r' OMonitoring DRecovery ft. ft 1 - r-- Injection Well: ft. ft. DAquifer Recharge .0 Groundwater Remediation _ ,- 1:19:'SAND/GRAV1:13BACK(if•appliealile)':=- : — _.:.- 16,7 ❑Aquifer Storage and Recovery ` ❑Salinity Barrier FROM TO MATERIAL _ EMPI.ACEMENTMETHOD • ❑Aquifer Test ❑Stormwater Drainage ft. ft ❑Experimental Technology ❑Subsidence Control ft. ft ' 0 Geothermal(Closed Loop) ❑Tracer raw DRIYL'GINGI:oG'(iittac$uadittanarslieetiifneceasary)' ____ ___; :__�r ❑Geothermal Meeting/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,son/rock type,grain size,eta) Date Well Started '2. iZi w q2 0 ft 12- it -a�.r'�' - 4.Date Well(s)Completed: 2(S 1 Well ID# a 3 la ft .606,it /' L • ;1 7 i ( w•''Q7' ®e � 5e Well Location: Phone#:4IF a vl u i.., . - ft. ft $G"40i _313D ft. ft. MAR 1 2024 A '�pp`g iy' a 9yLL Facility/Owner Name Facility lD# ifa applicable) ft ft `'-- ^'' tY r�gPP ) lTlu;i rfir°tc t ?!. ^iaTii..3!:� .� �� It ►111 Li ttl L9�' S 8. .au ft it DAr�E t`3'J(3 ` . . New wlob'Q-lP Physical Address,City,and Zip 2 a(cIJ ft ft • v AS 1 el - 1:-•21:fit rARKRr.- _ »_ _::___---_, .-_ _ - County Parcel Identification No.(PIN) ` ' 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' (if well field,one lat/long is sufficient) 22.Certification: 6.Is(are)the well(s): ''ermanent or ❑Temporary Signatur• e of Cert ed Well Contractor Date By signing this form,I hereby certify that the wells)was(were)constructed in accordance with ....® 7.Is this a repair to an existing well: ' ❑Yes or io 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy 7. If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner. repair under#21 remarla section or on the back of this form. 23.Site diagram or additional well details: 8.For GeoprobelDPT 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-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 9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3®200'and 2Q100') 10.Static water level below top of casing: ,D CC) (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: 6 (in.)Bit Off: to.031 24b.For Injection'Wells:Copy to DWR,Underground Injection Control(IUC)• , {{ Program,1636 MSC,Raleigh,NC;27699-1636 12.Well construction method: a i to Tta IN 7 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed rp FOB.WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA r i Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) I E Method of test: IA l3 (A i r - o y® Date Site Visited: / , 13b.Disinfection type: 70�o hth Amount: 7 OZ Site Visited By: . l , I Form GW1 —.-. ____ - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 Price:_