HomeMy WebLinkAboutGW1--06900_Well Construction - GW1_20241118 • .
• V4LL CONSTRUCTION RECORD (GW-I). For Internal Use Only:
1.Well Well Contractor Infor. ation:
1 .
A .N I''' .. ... Rit.w.xiuzosiz.v.,..,z1.•!--'••':!il•-••••• • - '• 'j'•••• --': ..:;::Z-•• • •-.-
FROM TO .•' DESCRIPTION
Well Contractor Name 114 ft. IIS ft seii- 6• i-- 9 a-Pt/Laza- ,
tle„Lue... - L-151.15-4 .31-tx ft. ( ft. fokre.. 0,6P1%1ceC4 DD
NC Well Contractor Certification Number .-S.'01-ITER:dSMOVOFtriiilii.aldd-,:1;iellaY:OlaaVERVatirliMIW: :-.•... : -S
Yadkin Well Company, Inc. FROM TO .DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name&ve4e1AZ-41.-C-MINERICASING2012713BlWaetarifiblinlagnikr)7%... i.!!?- 6
2.Well Construction Permit ft:Ms.&IMP 2 0 2-1 V- .3"9,117 FROM TO . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC County,State,Variance,etc.) t I ft' 19, ft. (AN ix.. 61A.- i Pue C} ----
ft. in.
' 3.Welltise(check well use): ft. ...
,17=mv.::: =-27.1.,•,:,:2:°1•'.,-..
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ...1-
DAgdcultural [Municipal/Public ft. ft. in.
0 Geothernial(Heating/Cooling Supply) desidential Water Supply(single) ft. ft. in. ---Ar.,
DIndustrial/Cornmercial °Residential Water Supply(shared) s.61X- ' • . . '. ' .'-.°1 .7"..'.'.',.:'.r--'2:.:,":5;-,0".7-:'11;-..f.-7,n!..2`;'1';,--XL,:j W
DIrrigation . DWelLs>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOTJNT
-Non-Water Supply Well: t) ft
' ft
' alAff6 ag, aas Aktucity
DMonitoring DRecovery ft. ft
Injection Well: '
ft. ft. . ..
I:Aquifer Recharge OGroundwater Remediation
1119:.SANDT4R0X12-13A.MiMfikiiiire);.1.1'tlr. .-siP. -:',:ani71.7,1.fi•--.Sn!S:
DAqitifer Storage and Recovery I:Salinity Barrier FROM ._ TO MATERIAL EMPLACEMENT METHOD ' •
DACiuifer Test OStormwaterDrainage ft. ft. 1
DExperimental Technology CISubsidence Control ft., ft • -
-
liGeothermal(Closed Loop) - OTracer
FROM ESCRIPTI ,hardness,sroc g
OGeothermal(Heating/Co olin,g Return) ClOther(explain under#21 Remarld)
TO f1.1 -,2/..- - 0 - ft. 6 D ON(color ail/ k type rain site,etc.)
Date Well Started i-if-
!E. _ . . _._ .
4.Date Well(s)Completed:[I-k-D..1 Weill:NA-A.61- `3 f G ft .11., ft
5a.Well Location:' Phone#: 9 ib-"7122''1 '.5' VS ft. 1 ft. 158I4F Ian tCkr'a‘111-L ,
0.
1:31,,,,. Ara,J,„ti ico, ft 1j09..ft. ma 1-yarb 18tVv-toW SariPrIt
. Facility/oWnerName ' Facility Mit(if applicable) . ft. ft V
1077 ' -s-hfa e.r-- fiirkki Atooklevil-it Nei ft ft
.
Physical Addir...?,City,and Zip 1%, / ft. ft
I10.1aitAnkluts:;g:..ex:::E.,.,-ii.sio:F...t'g?..,, mx..`::::::77r"ff.-, ,I'r,7!.47.e.:::?Z :':.n11-3:: -.4.;MWT •
re>7
County ' . Parcel Identification No.(PIN) .
' NOV 1 6 'cOL11-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well field,one 1st/long is sufficient) 22.Certification: ir,::."-.:.-.-..:
3a-- s-3 Si Y ' N Ro, 3q993- . .No • E3
6.Is(are)the well(s): Irafermanent or Egemporary Signature o ed Well Contractor Date
feerit412, -
By signing tins'form,I hereby certify that the well(s)was(were)constructed in accordance with:.-_•
7.Is this a repair to an existing well: DYes or leo • 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a Copy.'..
. ---- -
If this is a repair,Jill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
-.-_-_,-'
repair under 421 remarks section or on the back.of this form.
23.Site diagram or additional well details: . .! . .
8.For GeOprobeMPT or Closed-Loop Geothermal Wells having
You may use the back of this page to provide additional well construction info '
..'
the same
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: 2 24.SUBMITTAL INSTRUCTIONS .u•
9.Total well depth below land surface: (ft')
• LI 0 '
GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: SO (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ,
11.Borehole diameter: '(P. (in.)Bit Off: 506/92-- 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigla,Ng 27'699-1636
. 12.Well construction method:A le Fiv IN.-y 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. or Water Wells producingover 100,000 GPD:Copy to DWR,CCPCUA 7
Perrasit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test: t -i 03- I
• , '-:-Date Site Visited: /-&--'2-V
•• 70% hth -o9
oz . .:, Site Visited By: O Glob •
. : 13b.Disinfection type: Amount: 7. 11(..g . ; EN3
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... Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 6-6-2018 V
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