The URL can be used to link to this page

Home My WebLink AboutGW1--01707_Well Construction - GW1_20240315 1 WELL IJ C't IN 3 R.UCli 1ON •DDIRTy 1GWW-1) For Internal Use Only: • 1.Well Contractor Inform Ian: I , e.,,i3 9 i'6 �Qii 1A(,'t{3 14"$t )14.WATER ZONES I ;1 FROM TO DEscnmTION ,A Well Contractor Name .. I A S f' i 2 ft. 1 : , Ga PJ_, n ` S�� ft. ft. 11 VVV NC Well:ontractor Certification Number 15.OUTER CASING(for multi-cased Wells)OR LINER(if ap licable) •YAbKIN WELL COMPANY,INC. FROM TO DIAMETER THICKNESS MATERIAL 1' ft. ft. I: I in. (;ouipan•,r Name' w n 39 16.INNER CASING OR TUBING Geothermal dosed-loop) 2.Well Construction Permit#: w 2 -. 0 2•%6 0 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) (9 ft. 1..Ct ft. 1 n I`e/ to. 17 O p 1 1CLC rl 51Z i 1Y ft. l� ft. V all in. 3. ,al.l;Use'(checkwell use): ' 17.SCREEN I Watt?Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL OAgricultural OMunicipal/Public rt. ft. iru ❑Geothermal'(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. ill: ❑Indu::trial/Commercial . ❑Residential Water Supply(shared) 18.GROUT I ❑Inlgatioll r ❑Wells>100,000 GPD FROM TO (� MATERIAL EMPLACEI4 'NTMETHOD&AMOUNT Non-Water Supply Well: 0 rt. ��2It' > 1O(19ro0 Tl,ek. \ , 0a+chc5 ❑Moii ioring • - ❑Recovery ft. ft „ I Injecti:u Well: ft• ft. I ❑Aqui'er Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) 2 ❑Aqu•;:er Storage and Recovery ❑Salinity Barrier FROM. TO MATERIAL EMPLACEMENT METHOD ❑Aqu:er Test 0Stoimwater Drainage - ft• ft. I ' xp E r:imental Technology ❑Subsidence Control ft. ft.. ❑ Xeo''ermal(Closed Loop) - - ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) 'FROM ' TO DESCRIPTION(color,hardness,soiUrock type,grain size,etc.) ❑Geo'.iermal(Heating/CoolingRetum) DOther.(explain under#21 Remarks) • Q l ,ft. �� ft. ,501 '1 4.Dat.Well(s)Completed: I�a3'a 1 Well #dj ®®d`� �O .ft. rl�,) ft. (A� ( �nv' �w.Sm� • ;ft., • • .. ft �J I • 5a ti1':llLocation: Phone # ci i q-40 g-2f.31- �. b,' ' -, _ � . . _ - ft.; ft. t <� I. el by ' l'Le'(. A z.1 is- Fa..i''r Owner Name Facility ID#(if applicable) n•, ft. ' il•., 1 MAC, Z024 z- 60 nv. . .,.Ck:ope-t 14 r 1p„ ,ft., ' ft. . Physic.i P d&css,City,'and p , NC 1 �l'�J"�Vl ft ft. tftn:rii 12,,'�,Z D 6`'4,vt�. :...a....., , 21.REMARKS °�Crr'j ' Count Parce]IdentificabonrNo (PIN) BORES •(3)6..BEPTH (3 .& C!)f,..6-ej .2 7, f 5b.L. t tude and longitude in degrees/minutes/seconds or decimal,degrees: LOOPS PER BORE ( ) DIA OF LOOPS( ) (if wet field one lat/longis sufficient) 22.Certification: �. • OF LOOPS ( a� ✓� 6.Is(, -e)the well(s): + Permanent or •DTemporary (�l'!atnr. ut ".ed Well Contractor• Date By signing this form,1 hereby certi9 Ilia(the wel1(s)was(were)constructed in accordance with 7.Is• .is a repair to an existing well: DYes or Ao 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy If this I 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 nder#21 remarks section or on the back of this form. 23.Site diagram or additional Well details: 8.Fo. Geoprobe/DPT or Closed-Lao Geothermal Wells having the same You may use the back of this page to provide additional well construction info coast i lotion,oq1 GW41 is deeded. Indicate TOTALNUMBER of wells (add'See Over'in Remarks Box),You may also attach additional pages if necessary. drille CC 4ey 24.SUBMITTAL INSTRUC1_ONS ' �c5.� . 'o ri well depth below land surface: (ft.) I ' Fo• (iple wells list all depths if different(example-3Q200'and2Q100') Submit this GW-1 within 30 days(of well completion per the following: ft. 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.St=_tic water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 • If wale-level is above casing,use"+" i • Bit Off: .5-ilia- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC) lI.Bc reiiole diameter: `' (in.) Program,1636 MSC,Raleigh,NC 27699-1636. AIR ROTARY • i i' 12.V :11'construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (i.e.or er,rc:,-•. able,direct push,etc.) county environmental health department of the county where installed , • • FOR PATER SUPPLY WELLS ONLY: 24d.For Water Wells producing lover 100,000 GPD: Copy to DWR,CCPCUA. Permit Pro V I 13a. field(gpm) Method of test: Pt 1 e gram,1611 MSC,Raleigh,NC 27699-1611 p iP 11 !I LU(ha 13b. isinfection type: , Amount: 't OZ DATE SITE VISITED: VISITED BY: .. ,.r..l:,.r___r...,r,_.....a.........rc...,-,......_,,..i n,,,,t:.., n:.,.........tm„.-n__,..._f_I .,--' A-e o