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HomeMy WebLinkAboutGW1-2022-03415_Well Construction - GW1_20220315 L91-I&C LION RECORD (GW-1) For Internal Use Only: "1.Well Contractor Information: 4 � p� 14.WATER ZONES r Well Contractor Name FROM TO DESCRIPTION. ,j , ®3 ! V ft. ® fr. g �140- Nil . . „ S3 y� i NC Well Contractor Certification Numbs v ft• 2 Z L7�' "ti '�0 7�'�® ®y v. `�* 15.OUTER CASING for multi-ca ed wdls ORLINFdt d a lira e YADKIN WELL COMPANY,INC. FROM TO DUKWMER TffiCBTVPsSs. WATERUL. ft Company Name q y,' 16.INNER CASING OR TUBIIYG(geothermal closed loo s` Z.Welt Construction Permit#:2-1 - I " yV �}�'�� 1 FROM To nIAMSrSR TMErams: UTMUAL, List all applicable well constructlon pw7ils rix.EUC,County,State,Yariance,etc) ft g 0 0 in. �t� s 4 '16 G N/. NU 3.Well Use(checkwell use): ft ft. 17. Water Supply Well: FROM TO DIAKr= SLOTSIZE TH1C1CNC9S MATERIAL ❑Agricultural *Iinicipal/Public r ❑Geothermal (Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ' ❑Industrial/Commercial ❑Residential Water Supply(shared) l r tp ❑Irrigation ❑Wells>100,000 GPD B•GROUT „T,4 FROM TO MATERIAL ISMPLACEMENTT4Lr'[HOD tAMOIINTd 1��lt� y, Non-Water Supply Well: Q it ft. H [�•, ��t ❑Monitoring ❑Recovery ft. ft. A Injection Well: ft. ft. ❑Aquifer Recharge ❑Groundwater Remediation Sr []Aquifer Storage end Recovery ❑S _19•SAPID/GRAVEL PACK if a likable ! , Quife rage ery allmty Barrier FROM TO MATERIAL LrMPLACCMLNTMErHOD ❑Aquifer Test ❑Stormwater Drainage oz zn ❑Experimental Technology []Subsidence Control 20,00000Fft ",001ft /0,1l i ❑Geothermal(CIosed Loop) ❑Tracer C-20.DRILLING LOG attach additional sheets if necossa { � ❑Geothermal(1leating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESC[=Ox color,hardness saahoctc *etc 4.Date Well(s)Completed: ®—Z We AA ll D# 0 7 R ,;�,•� � S` `' a � �'4se .ir{� Ar✓ ft fk tws � 52.Well Location: Phone # �.fc��rc7-6 a t,�- 12•T� � _ , V iJ f p ft —I y!� �7a! _ C�/�aA.- Facility/Owns Name 1+�ID#(if applicable) '11L-ld It �fJ ft* � r ��r�� ,a t o / -}�. L ft• aoA ye- IgJ4� Physical Address,City.and ZIP a r ..y I[J, ft. ft i " 9~r _l 21.REMARKS County Parse]Idantification No.(PIN) ttAMAJ � t 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ^' - (ifwellfielcionnee lat/longis sufficient) 22.Certification: 76 / Ti �-J N 7 W 6.Is(are)the well(s): 4ermanent or ❑Temporary Sigaatnre of Certified Well Contractor Date By signing this form,l hereby certify that the well(k)was(ier)constructed in accordance wrth 7.Is this a repair to an existing well: ❑Yes or �Io, 1 SA NCAC 02C.0100 or 1dA NCAC 02C.0200 Well Construction&imdards and than a copy ® If this is a repair,fill out known well construction information and explain the nature ofthe of this record has beenpravided to the well owner. repair under#21 remark section or an the back ofthisform. 23.Site diagram or additional well details .�- S.For Geoprobe/DPT or dosed-Loop Geothermal Wells having the same stiucti You may use the back of this page to provide additional well conon mfo construction,only 1 GW-1 is needed• Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: a 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: J (ft.) fI For multiple wells list all depths ifdiferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days'`of wr11 completion per the foilowtng:, 1 `� I 10.Static water level below top of casing: T (ft.) ems. For All Welts: Original form to Division of Water Resources (DWR), Ifwater level Is'above casing,use"+" Information Processing Unit;1617 MSC,Raleigh,NC 27699-1617 7 O 11.Borehole diameter: (in.) an Off: -7 /O 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) (" Program,1636 MSC,Raleigh,NC 27699-1636 AIR ROTARY 12.Well construction method: 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 FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA O t✓/�o Permit Program,1611 MSC,Raleigh,NC 27699-1611 e 13a.Yield(gpiL, Method of test:rr8 Q 13b.Disinfection type. 70%HTH Amount: OZ DATE SITE VISITED:8 Pri rP Aid y- r� VISITED BY: