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Home My WebLink AboutGW1--06988_Well Construction - GW1_20241119 . - . ., . ' /..,9 • ,. ! vvEti,CONSTRUCTION RECORD (GW-1) For Internal Use Only: . i (`) '' 1.-Well Contractor Information: < ie er/ (.0.30.41C t45 .,. 1 . Z1.4i*W.X.TARSONBftlj.;:::.i:. • 1, " ' - •' ':':"' •..:.1.-;. :'''''."...t.--,. • ' ON Well ContractorName FROM TO .•' DESCRIPTION CD'4 ft. c7,3"(71 ft 3 Gplyt 11 ft. Sig"ft. NC Well Contractor Certification Number • 7;3:57013TERf&S.SINOtfaliiiilfirels-dd4cUsT.0100EaCKIT—Ircall'Al5":7 ":• ..:•' 5— Yadkin Well Company, Inc. , FROM TO DrAmrEn. - rim:mess MATICRIZ.. - ... /-- l--) ft. ft in. Company Name gl"r6INTNRIWASTNG:011.:ATIDITOggitliiiiiifil-CliSia;16irr :1:..:1:..‘.>:',.._::.. D 2.Well Construction Permit#: 0 . FROM TO • DIAMETER TRICRNESS MATERIAL n--. • List all applicable well construction permits(i. ElIC,CounV,State,Variance,etc.) , if ft• q j ft. i/m, in:, stigc), pvc -s 3.Well Use(check well use): . ft. ft ' in. • . Cl- ..;, •••••••-.-.-....,--4.,..,r.:25L.e, -1,.7. .s-,-..,•,: ,,,lif--- ,•• ..,:,•- ; ., 0 Waler Supply Well: • FROM , TO D/AMETER. SLOT SIZE THICKNESS MATERIAL ..Kgricultoral OMunicipal/Public , ft. ft in. • :.• ,:• .. OGeothennal(Heating/Cooling Supply) °Residential Water Supply(single) — ft. ft in. '• ,,- °industrial/Commercial °Residential WaterStipply(shared) ,.• v --,-- ....—.• ........,...,-,.„.... •„.„,.- ... _...... ?.,18..GROBT4,11,1::-ST.-::,.-,:41:;•`,,---.1!iz.a.„-.:i.M:,•••, ...1:1,..' .1._,.......''')- ;I:-...i....-2 t•...:.....7.'".....,V.:.:..:'.. . ... * °Irrigation,,-- .. .... •f.'. .:•-•••• °Wells>100,000 GPD' •- • FROM TO 1VIATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Welli'-' " '' ""'"'" 0 ft. P i ft 1401c PI 1 Pa U fej c If)1 1145S . ' .r °Monitoring „on v I q 21.124 °Recovery ft. ft • 'Injection Well: '' . ft- ft. - . . • OAquifer Recharge•.-- -.,•---,..-..-,-•-•'..).:-.OGroundwater Remedial:ion 111.9:::SANtirGft _latle(feita1l'EOM:%:-,T,'..g.'Cl'Xa',..,..V,:::::"":71.":7:=--:-..'-`-,.'---..,:."-• • °Aquifer Storage andRecovery.3 °Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD ' • , '• : 04quifertest ' OStomawaterDrainage ft ft OBiperimentai Technology OSubsidence Control ft. ft. . , - ' DGecithermal:(Closed Loop) OTrader ';':•20'.'.D1t111-,INGTOG(ittliall'aditiiiiiinlieetiirtieCeigliy-)n:Z,:i:':?7,'ZI-57.:-7 77 1.:'...:"•-••=-1::',, • • .3 ft. . ,.. - ype, .. DQecithei-inal(Heating/Cooling etum) °Other(explain under#21.Remarks) PROM TO DES CRI71011(color hardness,millrock t grain size,ate.) 'Date Well'SStarted4 •- . . 0 ft 0 Sat I . . `4.pafp*ell-0).compleied:: Well DV Adt4,' (22, 3 ) ' &Oa ' 6ea n Ort, , . •i !,. -1! .:-••::-•-• ._,..,.-• •-s., : ' '- - - ' Phone#: 3 ,,J.°11.02.-duet 4k ft. ff. • . 5aLsWell LocatiOn: •,.. ' ' - ArPn 91. . . - • . . . ft. ft .., •',i' ', -, .\ ',..y• Tvae d,4-1.,L• Ott d...-94j • - - . ' ..• • • ‘. • .- .:::...:- '• Facility/ ',Ianie '' .' Facility ID#(if applicable) . ft. ft. . .. ,. . .. ....:'-•• goo 'Va'efrt ei a ft ,, P-:t A-j ..'. i).4-. #okeieli*ii• 1:4K111 1 . ft' , , .,‘ " • . e..; . t Physical AddreSsi City,and Zip '• . ' • • . • , a lavi. • ft ft. uj"1 k. j. r • . . • . :.2)5.-AElts.t.::,!: .-;:7)1n:;:1:-.;:•::rzt:„:zv.-:.,-.t.:-.!., ... i.:...':: -;'i.-;.,..-?,...1.-;:.-Ce:t.a.---..'•:.7-.:::..%::*.: --2 , . , County ' - . ' l'arcel IdrntificatiMa No.(PIN) 5b.Latitude id longitude in degrees/minutes/seconds or decimal degrees:. ' • . • , ' ' (if well field,one 1st/long is sufficient)) ' " - • '22.Certification: . 3C.A O 7 06.C.• . N ,rt. .0 k/ 2-ct: • •;> w .- • . . .., Ut,--j*.... '' ..7;:i.i,..!).2..:1(iii:•74.)q-: . ';;••.: Sigma e'alo;Itified Well Contractor , 6.Is(are)the well(s) lEtiermanent or -alippOrary . Dale By sig,ning this fonn,Thereby cal*that the well(s)was(were)construciedin ricCardanceWith'.' '‘•• 7.`Is this a repair to an existing well: DYes or 1°‘ ISA NCAC 02C.0100 or 15A NCAC 02C.poo Well Construction Standards and that a copy If this is a repair,,fill out lotown well construcdon infonnation and explain the nature of the of this record has been provided to the well?wn.er.:. repair under#21 remarlz section or on the back ofthis form. 1 . 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 aw-ys needed. Indicate TOTAL NUMBER.of wells (add'See Over'in Remarks Box).Yon may also attach additional pages if necessary.: ; . drilled: 24.SUBMITTAL iNsTRuclioNs'. , ..• .:. • • .,:.. 9.Total well depth below land sin-face: 414,P° ''(ft) , For multiple wells lill depths if different(trcample 3®200and 2@l00') Submit this GW-1 within 30 days of Well Completion per the following • .:,.- ,"•.•i .‘ . ...'.':'..* st a7 ' - s 24a. For All Wells:1,01.iginal • form to Division bf Water Resources.(DWR),. '10.Static water level below top of casing: I e,a (ft) Information processing Unit,1617 MSC,Raleigh, -1617 • . . .., • . If water level is above casing,use"+" 24b.For Injection-Wells:Copy to DWR.,'Underground Injection Control(IUC) • ' i \•-•• 11.Borehole diameter: a (in.)Bit Off G.aPo • , .., Program,1636 MSC,Raleigh,Nc 27699-1636 1 . A .12z,Well construction method: me 24c.For WaterSupply and Open-Loop 1%ciltr-cci GeothermalS RetuniWelli:Copy to the .(i.e.anger,rotary,cable,direct push,etc.) county environmental health department ofthe county where installed. ...-___ —. 0 ....' - EifikW.A.-TEll.SUPPLY WELLS ONLY: . • 24d.For Water Wells producing over 100,000 GPD:.Copy to DWR,CCPCUA.. •-„. . -.. .,.._ a 13a.Yield(gpm) \ -I A.' Method of test: PA te Permit Program,1611 MSC,Raleigh,NC 27699-1611 1 . al oz hth .. Date Site Visited:3- -117 -Z.-Yr, • --..., 7 % . 13b.Disinfection type: `-•,„0 • Amount: a A Site Visited By: nays •1.:f - , !.i . ' •-?'' ' .., ..... - - - .Fenn OW-1 •; '\ North Carolina Department of Environmental QUality..-:DIVision of Water Resources -''-:, • • :".... . Revised 6-6-2018 . Price: 2 0, 2a . .....rQ 7 0-Q. .. _.