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Home My WebLink AboutGW1--06991_Well Construction - GW1_20241119 II WELL CONSTRUCTION RECORD(GW-11 • For Internal Use Only: 1 Well Contractor formation: 0) ( 4 F K;,, * `id Y 1 �S1d:WfiTE$7oNF�S, i�. i''..,T.: (f FROM TO DESCRIPTION Wertont actorName ft, !27 ft. i NC Well Contractor Certification Number :fi:16,0=R('.AS1NG'(fatmulti;"easedliieIIs7`:OR Li(if rliMig'::i.•:11 ::. ;. - Yadkin Well Company, Inc. PROM TO _DIAMETER THICKNESS MATERIAL . ft. ft. in. ' Company Name `.;..,. :'W<i'• �� / .Zi16'1 111M.It:C9.SING-ORai"UBINOVelitlie3 liiirao'se Inlii ••. 2.Well Construction Permit#: 0.2(0 2.,Q.,C ` 2.f • PROM TO DIAMETER TMCKNESS.Y] 'a MATERIAL List all applicable well contstructionpermits(i.e.UIC cow*,State.Variance.eta) I.1 it ASP P Al rn' S-PRi 7JG.• [�- • 3.Well Use(check well use): ft, - .. ft. •1 in 1' .. . •. Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS� '':MATERIAL I ❑Agricultural ❑Mnnicipal/Public ft. ft. hi. ❑Geothemial(Heating/Cooling Supply) li�dential Water Supply(single) ft. ft ' in. - ❑Industrial/Commercial ❑Residential Water Supply(shared) :%il;'G'RODTS:_:•:;` ,.%.i `'`_;r=,:::° �:t.' " e'er'-, ❑Irrigation •-• .. : ❑Wella>100,000..GPD FROM TO MA EMPLAC#MENT METHOD&AMOUNT Non-Water Supply Well:. t." "� "" ft 9A? ff. =1�(( ,lfaitY i3)3a5S t_ ❑Monitoring • , c if Racovery ft. ft Injection Well: Iv O V x - ft. ft `: DAquiferRecharge _ -,-•;OGrouridwaterRemediaiion ,-, � 'I9::SAND/GI VirrilE*ACgC r`iigiliII::" ::- +:z`{��2 -"_:.ii:._ •' -y ` • . ❑Aquifer Storage andRedovery u:u,: _..❑8alinity Barrier FROM TO MATERIAL EMPLAC MEETEMETHOD ` - ❑Aquifer Test ❑Stonnwater Drainage ft, . ft .-.. ❑Experimental Technology''..- ❑Subsidence Control ft.• ft. '`" ' DGeothexmal(Closed Loop) ❑Tracer i:•20111RILTING OG:(attdcl aaditio`nirklieite5f'neer'ssiiy)':: "•_;i'c -:°-:�`;ZR:-. . ❑Geothermal(Heating/coolingRetum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness;sail/rock type{mfa'aize eta) Date-Well Starte -?- 30 ft.• 3� ft 5 i i - 4.Date Well(s)Completed: ID 2 Well #A/44"23 ? .)7 )21 ft 340 . 5a Well Location: I / !( Phone#: -$ • /®7 ft ft Ake ►� 4- fO ir Mat ,. - ft. ft. ' 7 • • Facil$y/OwnerName Facility ID#(if applicable), ft ft C 3,9 aw Ii4rA ! Cf 'e-eACIAI 14bilvdik. ft. ft. Physical Address,City,and Zip it it 4(44 HI i 2L'eS,-REmmaTCfi:''w. ::.. :.........- .x, ,. ...:-iis;:.rr.....J'. v _pr E.: County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one let/long is sufficient) 22.Certification: 0,,.4) ; 6.Is(are)the well(s): Ii ermanent or OTemporary .dni,",,,,- Signature of Certified Well Contractor Date .By siigning this forrn,Thereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or 111V o 15A NCAC 02C.0100 or ISA 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#2I remarks section or on the back ofthis 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 constmction,only 1 CIW 1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. CP drilled:' r 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: )9a. (ft.) Submit this GW-1 within 30 days of well completion per the following •� For multiple wells list all depths if different(example-3 e®200'and 0) - i- 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water Ievel below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" -11.Borehole diameter: 6 (in,)Bit Off: i,Y: 6 9- 2` •For Injection'Well's:Copy toDWR,Underground Injection Control(I(IC) /� / Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method:�/i' 4 Y r j F1/ 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 1 FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA ri Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) l Method of test: l 70% hth Date Site Visited: C`z I 2 V - `� 13b.Disinfection type: Amount: 6 OZ Site Visited By: ` r)0 _ -__ Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 ..-. - .e 1