HomeMy WebLinkAboutGW1-2021-05306_Well Construction - GW1_20210615 T
A %A I�cV l e 2 ft. q
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7?Well Contractor Name T FFCPI TO DESCROTMil
3 U'A - ft.
RC Well Contractor Certification Number v0'3 r
'. 11 15.OUTER CASING(Lor multi-casid
Dells
e�j"0 Iv ) ffapplicablej
YADKIN WELL COMPANY,INC. �T;''J
Company Name
16.VNER.CASING OR TUBING(Eeathermal closed-loonl
2.Well Construction Permitt 5 5- 91-15- FROM TO DIA ME-TER TH[aMSS MAMIAL
List all applicable well construction permitfrre.LUC,County,State,Variance,etc.) ft
AC r ft.
C So in- V
3.Well Use(checti well rise): ft. ft. in.
Water Svtpp;y Well: 17.SCREZ,N
FRO rd TO DIANETEP I SLOT SIZE I 771- 11,rrl-,,Ir I I-1—ilm-L
DAgricultural j Olviunicipal/Public it. ft.
OGeotherrnal(Heatin�Cooling Supply) Residential Water Supply(single)
,- I It in.
01ndustriaYCominerci al DResidential Water Supply(shared) ILR.C-ROUT 4-101
01trigation OWells>100,000 GPD IFFON TO MATERIAL
Non-Water Supply Well: 0 it. ft.
DMonitoring DRecovery
Injection Well:
OAquifer Recharge OCTroundwatrr Remediation ft. ft.
DAquifer Storage and Recovery 19.SAJ%ID/GRAVEERLPAA-C
OSalinity Barrier rpord To I MATIERL&L ENUU-MrM4-1 METHOD
OAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft.
OGeothermal(Closed Loop) OTracer 20.DRMLING LOG(attach additional sheets if necessary)
OGeOthermal(Ifeating/Coollili Rettim) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION. (color,hardnAess,saillrock type,gmin sae,em)
ft. .92 LJJ�-. ft 0 C, It
ft 4.Date Well(s)Completed: 5-,,Ir -
) 2-1 WeH 1D# ft. J
'15- - T— so,,C/
5a.Well Location:
Phone # 9*3 3 Lb--ft- S I
ZoL AV e r&w e-,M(r A0 W S- I ft. ft* ^ e
-4 ft.F;CWty7-0wiierName Facility M#(if apilicable) ft-
iv r P/A C 162 el
Ef
Physical Address,City,and Zip ft. ft.
Wei !65 21.REMARKS
county Parcel Teienti cation No.(FIN)
5b.Latitude and longitude in degrees/minutestsecondsor decimal degrees:
(if well field one lat/longis.safficient) 22.Certification:
I-el N 9/ 3 7, 743 1
7
6.Is(are)the well(s):Permanent or oTemporary Signatu>ro of Certified Well Contrac or Date
By signing thisform,1hereby certify that the well(s)was(Were)constructed in accordance with
7.Is this a repair to an existing well: OYes or Xvo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard;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#21 remarkr section or on the back of this form. 23.Site diagram or additional well i details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pageb provide additional well construction info
construction,only GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarics Box).You may also attach additional pages iftecessary.
drilled: 4L 24.SUBMITTAL INSTRUcnON S
9.Total well depth be low land surface: (ft)
For multiple wells[Wall depths#-&fferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
+ I% I
' 24a. For All Wells: Original form to Division of Water Resources (DINE),
10.Static water level below top of casing. (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above coring,we 11,11 i I
4� (I. Bit Off: el i 40 24b.For Injection Wells:Copy to I DWR,Underground Injection Control(IUC)
11.Borehole diametel:
I — Program,1636 MSC,Raleigh,NC 21699-1636
12.Well construction'method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return
(ie.auger.rotary,cable,�Mct push,etc.) y vironmen department of the county where installedWe"
11 Copy to the
count en
FOR WATER SUPPLY WELLS ONLY.
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MR;,xaleigh,i NU 27699-1611
13b.Disinfection type: 70%HTH Amount: Oz DATE SITE VISITED:,
C. Pe VISITED BY.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018