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Home My WebLink AboutGW1--06147_Well Construction - GW1_20241014 .----- -1� AIL CONSTRUCTION RECORD (GW-11 For Internal Use Only: 1.Well Contractor Infor+m'ation: �A I u�U1 d: (�V-c �14 WATERZorms:7_-:;3;ir, :.2:; I.!R'.<i^'..._ :_ �...._ �__s:...• . Well Contractor Name FROM TO . • DESCRIPTION ri S ft. ri 7 ft I I F'Ot;1 U/Ti 15-(17‘.-4 I Olt' .IO 17 ft' Sift 4111r4), ?wate c j NC Well Contractor Certification Number ,15.:OUTER•CASING(foiemulti;eased:Sve1 '.OR :(ifap"licable)L_':;`� •: :=:.�a,J Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1 MATERIAL lP. ft. ft. in. Company Name ---". : �] °1 �.i�16`IIalER'CASILIG:OR'.TITBING;(t;iiotber'miil closed=Iaop):��.,�:,__^ .�_�'�:•`;.'v''r>s ;;� 2.Well Construction Permit#: 41 O 4o / — 1 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) 1 ft. 21 ft `t a SQ in. . (8? G.v. S'1[e ,( -ri- - 3.Well Use(check well use): ft ft in. CO) Water Supply Well: FROM O DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft -ft in. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in. ❑lndustriai/Commercial;.: s- -:..*Residential Water Supply(shared) J18:7,GROU'I'Ln"-.": -✓--` ti -_--_.. ❑Irrigation J n:,..-, ^., 1..:, 17We11s, .100,000 GPD FROM TO MATERIAL _ EMPLACEMENT METHOD;AMOUNT Non-Water Supply Well: 0 ft 9.9 ft .p,�.i4n j)b CI p i pd�r{/` :Monitoring • 0 C T 1 ... ? °very ft. ft l p h[�s . Injection Well: E. `� r ft. ft `j , DAquifer Recharge Ir, -'-':•"'''....'"-' - .❑GroundwaterRemediation _ _ _, _ ___ (:'.";•.,.. ;'.::i i319i:SAND/GRAVEVPACIC'(rf"spplicalde)i.l:.— �` . . ❑Aquifer Storage and Recovery „,"„ OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD T - . ❑Aquifer Test , - ' ❑StormwaterDrainage ft. it ❑Experimental Technology CI Subsidence Control ft. ft. ❑Geothermal(Closed Loop) OTracer =20:DRI1:<LSRGI;OG(ittach addifiiiiili sheeti.ifiiiiiss`ary)" .L.._ _____-_ 7_3 ❑Geothermal.(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soii/roek type Brain size etc) 'Date Well Started. g..tqc—Z ^/�/� fc. ft '5('9/.l . ' `,4:Date,Wel1(s)'Completed: P-,(-Zy well ID#.4 0—dog 4 it. 7 5- ft k carol 1 t k 9/4. CJ F .'1 Phone# of . ' 7/6 b.33 1 7 % 1 ft ' 51.Well Location ►drys ? /G /e f�ENa tr p/�O�J/� /`� /�Vn} L I I ft. l IO ft 1 Gr/ ® 4. /Afi G/c,.y ra9I �: . LV/i ek d J' i�ii ( 1.7i. 'i J? I.Z - _1 g J 5 Facility/OwnerName Facility lD#(if applicable) ft. ftIV ft. ft. 'S L, j Pet Sadipt ,,1�ls6a7 Pliysical A ,City,and Zip. _ ft. ft • (ova�'�►.in4'.. -.1 County: Parcel Identification No.(PIN) - • ,: '•: •5b•.Latitude•and longitude in degrees/minutes/seconds or decimal degrees: r.- 1(if well ield,one iat/long is sufficient) 22.Certification: '36'f'' ill" ecI. l ‘' 4 °' �_(_ 2� N w �' 6.I(are)the well(s): ermanent or ❑Temporary Signature of Certified 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: DYes or Afro ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy ' 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 remarks section or on the back of this form. 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 1• ,' 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.SUBMITTAL INSTRUCTIONS I. (�l 9.Total well depth below land surface: 1 0 l (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3Q200'and 2@100) 24a. For All Wells: Original form to Division of Water Resources (DWR), • I0.Static water level below top of casing: 1�o` (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ,,,:':If Water level is above casing,use"+"' 11.Borehole diameter: 6 (in.)Bit Off: Co I l er S. 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) . Program,1636 MSC,Raleigh,NC 27699-1636 -' : 12.Well construction method: /.Pt I f trip*AP. 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 Permit Program,1611 MSC,Raleigh,NC 27699-1611 4' • 13a Yield(gpm) ( Method of test: f i % . t Date Site Visited: o ® ,e� • 13b.Disinfection type: 70° hth Amount: "f'O .OZ Site Visited By: A4 R. I • AP' . J-, (4. 1 Form GW-k North Carolina Department ofEnviroamnntal Quality-Division of Water Resources 1 Revised 6-6-2018 • Price: .30.,. e+