The URL can be used to link to this page

Home My WebLink AboutGW1--05154_Well Construction - GW1_20230814 / • /WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1,Well Contractor Information: , , � V'tS ut.S J.e v-c>w�e W x4:;WATER ZONEs' .. :':.:<: Well Contractor Name FROM TO DESCRIPTION , U ^I dIU ft. aft. ft. ft NC Well Contractor Certification Number .:15r OU11i t CASING(for:mniti=aired:3vetiSIORLINER(Milli-lialiTe) _ ' :_. 7- Yadkin Well Company, Inc. FROM TO DL4METER THICKNESS MATERIAL. Company Name 1 ft. gel ft. 6s! in. De-sl f Pu 3 p� ( `i16.INNBR CASINGOR.TIIBING`(e'otlieimal'd sed=loiip)' -._ _ _ 4,• ® 2.Well Construction Permit#: 1 P�( 2.6 2- OC g�. FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(Le.UIC,County,State,Variance,eta) ft ft in. ft. ft. in. GO 3.Well Use(check well use): ` ' Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL S. ❑Agricultural ❑Municipal/Public ft ft in. 5, OGeothermal(Heating/Cooling Supply) ffilesidential Water Supply(single) ft ft in. ❑IndustriallCommercial _ ❑Residential Water Supply(shared) - - - r ::18:,GROUTv: -. i ❑Isigation ", l 1' .�C1,F o 4;Veils>100,000 GPD FROM TO MATERIAL EMa () k CEMENTILETHOD& ANNT Non-Water Supply4Wellr''n'"'"* ft. D ft fie„ ui are, i'in i /etc - ❑Monitoring n t f r 1 ._ 7[7' ❑Recovery P' ft. ft. Injection Well: HU lj - ft ft ❑Aquifer Recharge { itpr-.7+G:, ?- . oundwaterRemediation E19.SAND/GRAM PACK if illipliCa.bleY-..- __. _- ❑AquiferStor 0RutOrY24 -71 ❑Sal inityBarrier FROM TO MATERIAL EMPLACEMENT METHOD DAquifer Test ❑StormwaterDrainage ft. ft DExperimental Technology ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer T 20:DRIf.L NGIAG(attacli-additionlsshiet's'if neceisaiy)._�.._ ._ ❑Geothemsal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sosoil/rock type,grain size etc.) Date Well Started a I/ �( lffi3 ® ft. t fs ft Sol�/ S , S1 f/ ' Lbns e S63 4.Date Well(s)Completed:al/Trs/r/�3 Well s# - b- 6 (/ 5 ft. 51 ft 6 fraHr k 4 . /f ,.i 5a.Well Location: Phone#:5X.7i0..R•ro2. sq ft gq ft o?rat, (4' €i1ev5 /nIlle- e /-,� ft. ft. Facility/Owner Name • Facility ID#(if applicable) ft. ft 2 et2t ru iti P4acr.Cw Mil, A-IM ft. ft Physical Address,C'Ti �$� y,and Zip 7° ft ft ... :21_REl$ARXS:. .- ...... •. .. •.. --- - -- - , ...- County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certific.ion: 3C. I(-7 N TS-Qa (X 2oS' w l'rlITA-Iy/ a1-j 6.Is(are)the well(s): permanent or ❑Temporary S' .• o Certified ell Con or Date suing this form,I hereby certify that the welI(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: OYes or (r#No SA 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 th - of this record has been provided to the well owner. repair under 4121 remark•section or on the back of this 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 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: / 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 0 eli (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if d fferent(example-3@200'and 2@100')^ 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: l' (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" C24b.For Injection Wells: Copy to DWR,Underground Injection Control(11IC) 11.Borehole diameter: (in.)BIt off: r D Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: il tic A D'V y 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 ' D Method of test: ' t �'^'it� Permit Program,1611 MSC,Raleigh,NC 27699-1611 e 13a.Yield(gpm) Sep c Date Site Visited: e�/n-2-3 . 13b.Disinfection type: 70�o hth Amount: OZ Site Visited By: f): .AV 4 0 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 -13 Price --I