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Home My WebLink AboutGW1--05529_Well Construction - GW1_20240913 1 1 WEU CONSTRUCTION RECORD (GW-1) For Internal Use Only: -f ' 1.We Contractor Information: i61,P4 I d Via/pl Iiii.W.A.ItE LZONES'.•;/ �_�,;z..,.,., •°.; -: - . . ., i•'�:i::1:.: •. . . FROM Well Contractor Name �� DES I PT ION N • ft. ft 20 3 4 ft ft. 11 NC Well Contractor Certification Number :1 ''OD1r:CASING`(fm:mtiliii`a ed iieIIsl:ORTilNEILTrat•liallelln :i'....:•-.. Yadkin Well Company, Inc. FROM TO DIAMETER TRICErESS 1 MMTERI� ft. in. /" Company Name �' "S !� 0 a� 16 C-ASING:OR7W3DT.G:'fg'surliermiir'elaga-41adpT-:i[!%.�i;.; ' ;17-1 , 2.Well Construction Permit#: 02., 2- 6 e 2&(L FROM TO • DIAMETER THICKIHFSS MATERIAL List all applicable well construction permits(.e.UIC,.County,State, Variwwce,eta) + 1 ft• tat( ft 61,fif im -al&02 1 PVC •frO' ' 3.Well Use(check well use): ft. it . in Water Supply Well: aljacR i-S1`•.. ro. t:': Ii:11WI�,"r:>.;aL`?:t;'':.:i=' :=;:1^'=._.....,r'•: FROM TO DIAMETER SLOT Sint THICKNESS MATERIAL, DAgricultural ❑ unicipal/Public yt. ft. / in. ❑Geothermal(Heating/Cooling Supply) ',{}. idential Water Supply(single) L � in� ❑Industrial/Commercial (residential Water Supply(shared) . _•� i ii:18..GROTITt i•s;w x' • ..I.:7.t:.' :`a;,':i,1a .. . . ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: p ' g• R. 5- ft ` e,n ',mpt e, Citeip l 6Fr."iAP�bLy Q A ❑Monitoring - ❑Recovery ft c� ft. i Injection Well: - ft. ft ❑Aquifer Recharge ❑Groundwater Remediation i:•19 HAND/G12A'V ICEIMM rf appl ca e)s............ ?li` ...,,... . ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 0 MATR.RTAT. EMPLACEMENT METHOD • • DAquifer Test ElStormwater Drainage ft oz ❑Experimental Technology ❑Subsidence Control ft, f ❑Geothermal(Closed Loop) OTracer tr20:321R'1 TG');OG(sittachaadttiona`lslieeta'ti"n'eceisai7)'i -t!c=r,:.r•'•:.rA':`. -FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.) ❑Geothr..rmal(Heating/CoolingReturn) ❑Other(explain under 421ll mado) Date Well Started -., cal' �( A �y�y 0 ft I ft -Se:I 4.Date Well(s)Completed: '---�/Well ID#IAA( 510 it. ft ( s i Phone#:3,36- 2. -VS3-' /70ft �Y� it. Sk 6, �°t9-e. . Sa.WellLocaation: �y ry -_S Q Mn ' k dR2b r�AIµ91(CV_ �d 1Oft. 3(;4ft �IeAJ , Facility/OwnerName Facility 10#(if applicable) ft. ft. ,1 i `...r 1 ., • /1 7 S L,,1q n P-4 V�. d k 161 v,`112_ ft. ft. r,E, l t� .. ' Physical Address,City,and Zip ft, ft ' P ,�' �' , 202A Q� 0...t.l2Yr.A�r'13.70:':=l.4-2-.-.1: t-';;`5„ :Sts-- Z.'VX4A'.'• .,:L:.,U� :.:,i'-�;.s; -._.. County Parcel Identification No.(PIN) 10 `" lc/ el Or`�'VS 16.011 /%4'I...- f.,'':..,f i : Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one 1at/long is sufficient) 22.Certification: - ' • 6.Is(are)the well(s): 4.ermanent or ❑Temporary pp Signature of Certified Well Contractor Date BAs 14.C., t `� By signing this form,'hereby certify that the well(s)was(were)cotutructed in accordance with 7.Is this a repair to an existing well: DYes or To ' ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,frll out known well construction information and explain the nature of the of this record has been provided to the well owner. repair under 421 remark section or on the back of thisform. 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: / 24.SUBMTITAL INSTRUCTIONS 9.Total well depth below land surface: 3 10 (ft.) Submit this GW-1 within 30'days of well completion per the followings For multiple wells list all depths if different(example-3@200'and 2 b0) 24a. For All Wells: Original form to Division of Water Resources (DWR), oO 10.Static water level below top of casing: 4. I (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+' 14.Borehole diameter: (in.)Bit Off: 3 s 1 6J ®d 24b.For Injection-Wells:Copy to DWR,Underground Injection Control(hUC) Program,1636 MSC,Raleigh,NC,27699-1636 12.Well construction method: to g,fi' (s7 4'41 Pit 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 FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA e Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) C° Method of test: -d r 70o/o hth Date Site Visited: egg' A A If . 13b.Disinfection type: Amount: 2 8 OZ Site Visited By: Form GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources , Revised 6-6-2018