GW1-2021-00876_Well Construction - GW1_20210305

v - - ISr
A4I -�X-q.`WAY 7CR WHED.
Well ContrL to:-Name ".3- bF.096 I TO DE-SMET-10A
j
NC Well Contractor CertEff.afion Nuber
.
Yadkin Well Company 4 RE xo DIAP=,R. THICIMSS MATERIAL
Company Name ft'. M. I
• .-EVUOR T!Mlr,.TG- a6lied
2.Well Construction I?ermit#-- YROM
D11111,=3 m1rc aq 1s?S •116AM.
List all a 07C,Cowly,State,Va)YDnce,etc.) Ift 33ft I , *. P L
3.Well Use(check well use): M ft
Water supply well: TR014T rJ T-.A 0 1 DIA SLOTSIZE L
Agricultural nMunicipal/Pub-He o 7t.
nGaothei-inal(11tating/Cooling Supply) 5LIdentiall Water Supply(single)
Olndusbial/Cornnlercial r
JJR?sidEffdai Watei S-qpl,,(shared)
TO
— I D EMM-MMIAMN-I I—m-1HOD-_A31OUNT
lwoii-wnter Supply TV01. ft e
1, ,1;
ral/ 4
oldouitoring aRecovery
TMje9tl033 Well. ol E_Aquifer RtchaTge DCToupdwater Remediation
.a ii
Aquifer Storage and Recovery OSalinity Ba,-,itr FR0,11i TO l MAJERIA L
Aquifer Test Stormwater Drainage
Experimental Technology rpSubsidence Control Ift
Geothr rmal(Closed Loop) OTracer 2
0,
D2qc
C:Geothermal(Heating/CooUngRetum) 00ther(explain under421 Remarks) FROM ft To
A-
4.Date Weld(s)Completed: Well ID# J_Vr1,_ F?,- &V
Sa.Well Location: Phone numberj5i,_ s y n qf /::Y� ro see"qd--
zuldl nb I IRWIWA S q0 ft 6 1h
C J'a I
Facility/OwncrName Facay]D#CifaWlicablv.) ME
'OF 0 f' f' I ,A e.Jl
L ft
I A 4 1L, 5 f, 2-
9
Physical Address,Cii�%and Tap r
C,Imty Parcel Identificatian No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(rfwell fiel d,one I at/long is s affmient) 22.Certification:
W/
_.M
15.Is(are)the well(S)aermanent or MT—po-ry Signature&Cerdfied WeR Contractor Date
By suing this form,I hereby cerrt5,that the 31TII(S)'was(were)constructed in accordm?cE
7.Is this a repair to an existing well; UYes or IdN. wi'7115ANCAC 02C.0100 or.154 lVr-AC 02C.0200 Well Construction Stmidards and that a
brIhis ka repair,fill out 1mown well construction hiformation mid Explain the nature ofibe caw afthis record has beenprovidedA-;the well owner.
repair wider AW remarks section Dr an the back qfybJsftF7m. 23.She diagram eirAdditional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back ofthis page to provide additional well site details or well
construction,only I Gff. is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:- y - 8MMlTTAL INST-RUCTIONS,
9.Totalwell depth below land surface:_ K i (ft) 24i.For All Wells Submit this fbim within 30 days of completion of well
For multiple wells list all depths ifdffierenq(example-3@200*and2@,700) construction to the following:
10.Static water level below top of casing._ (ft.) D-ivisionof Water-ResnarcesLdormnt-i-on--P.-re-c singUn%
gwater hvel is above casing,use"+' es
1 1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter: -(4) Bit aff . 101 24h.For Iniection Wells: In addition to sending the Join to the address in 24a
above,also submit one copy of this form afthin 30 days of completion of well
12.Well construction method: construction to the following.
(ie.angex.-tax3%cable,directpush,etc.) -
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
. 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Method of test: 24c.For Water Snpplv&Iniection Wells: ID addition to sending the fbim to
.Disinfection type: HTH the address(es) above, also submit me ropy of this form witwithin30-days of
13b Amount- cups 3", completion Of well construction to the county health department of the county
where constructed
Fonn GW_3 North Carlin Dcpm-fiment ofEuvikoinoental Quality-Dildsion ofVirater.Resources Rmised2-22-2016
Date Site VisitsJ_V� 2-t ky:

CAl9r�1• .�L's �, � � � - fy' Viz,` " � - 3 !
� Io
�adorl;poE •Ot ��,�)f��'_1'. ,1;1;
it
Apb91C*nl: BILLINGS JOHATHl3t`:I
Addiesq: ISO BOX
1131
Cad.y'
y* latel2ip: IC!20075
r
i� Phone C:[phone]
`rrt• r.. �f#1(�] ��-����g6� S91,0 Infat IPif11�
I It3 0911g Phase: ?v"s:
iTss�'
- 'Proposed use of Well: SINGLE FAMIL`!
Directions If Other.
° T� �/R 31S;T/L GLADE VALLEY RD,T/L RIDGE GLEN RD,SLIGHT P.T PRESNELL RD LOT IS
1 R� p T _ -•
L..
t d W610 Cold F900ir Information �ry
Driller Registration:
s feftif Conditions
P rt Conditions� � �'.
II seiba"Ir cs as listed`m"15A NCAC 020 01Q7 roust be maintained. This includes maintaining a minimum of 100 feet
ro I arts o septic sys&-Mand repair area for shaped wells or septic systems installed in saprolite,25'from any
tl i e'meterAr Byattached structure;25 feet from any stream,;creek,or river,50 feet from any pond,50 feet from
n fuel ail tank and 100 feet from ahy livestock/animal bath;feedlot,manure pile,fertilizer;pesticid2,herbicide or other
emieal ora e:`;The welL_shall -Wb --constructed outside the approved area(s)shown on the site plan without prior.
i�! �, - 1
p r I fr m his-Department Well shall not be constructed in a designated right-of-Way, :Contact this Department with
ue io s p o ,t be innl6gfwell'conslruction activities. Owner is responsible for contacting this Department when well 1'
ead' r:omple a and r ady4orrwatei"samples to be collected.
I oration,consWdla an p ot�edion must meet all state and local regulallons and must be inspected and approved by an authored p
i paesen Iva of a Local"HeallhiDepaAmentk The permit may be revoked at;any time for f allure tb comply with existing regulations The siting of,
ad If nstnr on areas)by the Health Deparimerit is to provide protection from.the known posslble sources ofwntaminaUon The
ap vetl I areas) y not be ch ged wrlhout-permisston from an authorizetl representative of:fhe Local Health Department No votume:of
r a>��
qusrdy o/wale 1s guaranteed Eby the HY_ealttl Deparf1,
ed B : Ho der,Joe r
"Date of Issue: 12/04/.2020
Autho' ed S ate A gent.
Hand Drawing: Import Drawing
ched
3 f
bt

+�etj J(}7(J .4
f C
ry to'J' I S
J
Al
I ,
Glade !f
Valle .Rd
1:9,028
0 (105 01 0,2 rta
Parcels(Po!yyons)-Parcel. Projer+ed Route
1401-System Roads —ONe:SlateAgea_,Route 0 0.1 02 0.km
Federal Route —Seconday Route
N,in-S,oterm Pramary P.oads
t.ca;a as v ai e>r NM:.a l.af Ja-°•.FLLi4 C:[-++,r:,ti,r
OtltEtSystemPcEds �'In[efslatE f.x:u..ti.5 _a,rnf_,mtnal:rl Eea•-,RL tilt„SY..U.--h
triLkEi!C+A^•�JCT;tw^^!: LSGS C=p •.GS U:Cc+a•'.Qucr_
®P.amp;Rest Areas,i•lor-Idal ire —US Route L.^aaa
2/3