GW1-2021-00936_Well Construction - GW1_20210305

TELL CONSTRUCTION ION RECORD (GW-1 For 7ntesnai Use Only: •�
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1.Well Contractor Information:
VD�
� pp�'� Y9 WATER�ONES'
Well Coutracto&amc FROM TO yyyyg DES CRIPTION [•
J it S®C/it `l%ti(r1
J
NC Well Contractor Certification Number 5 ®ft D ov ft. `' 61 a
15.OUTER:CASING formvlti=cased ivell3'ORLIlVER'if a liiilile?:..:''
Yadkin Well Company Inc. FROM To ➢rAMETER THICKNESS MATERIAL
$ ft.
Company Name -
.:16:IL41YER CASING OR TUBING -eottie'rma!closeH lco
2.Well Construction Permit#:" 3 Lj FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.IIIC,County,State,flarionce,etc.) I ft "" �R�' �✓�
3.Well Use(check well use): ft ft �P in.
Water Supply Well: 17:SCREEN.._
FROM TO DIAMETER SLOTSTLE THICKNESS MATERIAL
F_Agricultural nMunicipal/Public 0 ft, ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in
Industrial/Commercial DResidential Water Supply(shared) -
.ag:GROUT .:.
Irrigation FROM TO MATERIAL EWLACE51ENTMETHO➢&AMOUNT
Non-Water Supply 1Tdell: ® 17��-.e[?' a u e
Monitoring ©Recovery ft ft. U
Injection Well: ��'.��u '1
ft. ft.
_Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery -19:SAPID/GRAVELPACK ff a','licable '
Aq g ry ©ISalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) MTracer 20:DRTr TING T 0G:-attacYiiiditionil sheep ifnecess
C Geothermal(Heating/Cooling Coolin Return Other FROM TO DESCIaTION(mlor,hardness,sorUrock type,Brain size,etc
(Ii g/ g ) (explain under#21 Remarks)
/) g' ft ft. e i V, Al -ci
/-��- e 14 3� ft ft. G, 1
4.Date Well(s)Completed: We11ID# �_ '� ,S`� � ��p�� ,�,` ��•-�it•- ��G
ft ft
Sa.Well Location: Phone number �,�jS- 3oa- J,8
yY JJ- a_ y ft ft.
1 Vlt'� L15 a W V9,�eeRZ t•Y u0ji n
Facility/Owner Name FacrlityID ft. fth(ifapplicable)
p f ft. ft d a
�''EW of Sy tV Z nr OGKSytr,
L&�v Physical Address,City,and ft ft
`� e 2L.-REMARKS. v _
(( �1/G\/t 2.
County PazcelIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one W/long/Iis sufficient) / 22.Certification-
Sb. G N �bt 7 e ( b w
SIC'
6.Is(are)the well(s) Permanent or Temporary Signa of Ce ' Well Contractor Date
7 By signing this form,I hereby certi&that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EjYes or o with 15ANCAC 02C.0100 or 15A NCACI01C.0200 Well Construction Standards and that a
If this is a repair,fro out knaa n u'e11 construction informarior'or explain the nature of the copy of ills record has been provided io the well owner.
repair under 921 remarks section or of the back of thisfarm.
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 site details or well
construction,only 1 GW-1 is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: �.3 0 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdOirent(example-3@200'and1Q100) construction to the following:
10.Static water level below to of Basin • Ut) ?
P g• s (ft•) Division of Water Resources,Information Processing Unit,
Iftvaterlevel is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Bit Off Ip•01 v24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: cA t f (I Z f construction to the following-
(ie.auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) YL Method oftest: f a 1 I. 24c.For Water Supply&Iniectioulwells: In addition to sending the form to
the address(m) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount. CUPS completion of well construction to the county health department of the county
where constructed
Fa®GW--] North Cazolina Department of F+v r n ental Quality-Division of Water Resources
5 Revised 2-22-2016
Date Rite Visitsf f Z-.2j-Z 6 26 by: ^q# 6e v
cs4
j .` I

o / COMPLETE IF IrTMICE GOES TO BUILDER
011 HERS NAME:_ ki Mau BUILDERS MAME:
ADDRESS: ('�/ '� Q6/!rd .5 l—,k ADDRESS:
PHONE# OFFICE#
CELL#
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Weil construction Permit For Office use Only
Davie County Health Department
210 Hospital Street *CDP File Number 290434
P.O. Box 848 PIN Number:
Mocksville NC 27028 Tax Lot#: Tax Block#:
Phone: [phone] Fax: [phone] Evaluated For: WELL
PERMIT VALID UNTIL: 7/912025
Property Owner: Gerardo & Mary Russell Applicant: Thomas &Whitney Shoun
Address: 8025 Broad Street Address: 1086 Mystic Lane
City: Rural Hall City: King
State/Zip: NO 27045 State/Zip: NC , 27021
Phone#: [phone]
Property Location & Site Information
Address/Road#: Subdivision: Phase:i Lot:
r ss/Wagner
r
agner Road *Proposed use of Well:
g
Moc svil
Mocksville NC 27028
If Other'
Latitude
Longitude Directions
Site Address:Wagner Road Directions:601
TL on Ijames;Church Road
TR on Wagner
less than one-fourth mile sign on right
Well Contractor Information
Drilling Contractor Driller Registration
. . . . . . . . ..
Permit Conditions
*Permit Conditions chain
Well must be: Rmain
382
-at least 50'from any part of septic including Tank and Repair area
-at least 25'from any building foundation including decks
-out of any drainage ways
Well location,construction and protection must meet all state and local regulations and must be inspected and a I Oproved by an authorized representative of
the Local Health Department.The permit may be revoked at any time for failure to comply with existing regulations.The siting of approved well construction
area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be
changed without permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the Health
Department.
N 6- aXr',OE�fl
"Issued By, 236 *Date of lssuei 01, 7 . / 0 9 / , a, 0 , .2, 0,
Authorized State Agent. I i
(9 Hand Drawing 0 Import Drawing
Owner/Applicant Signature: **Site Plan/Drawing attached.**
Page 1 of 2

VWCLA�%OW110I MOM i RAV rCnM11 290434
Davie County Health Department CDP Pile Number:
210 Hospital Street
County Pile Number:
P.O. Sox 848
Mocksville NC 27028 Date: 07 / 0 9 / a 0 a 0.
®Inch
Drawing Type: Well Permit Scale: 1 . O Block 6 0
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Page 2 of 2
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