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Home My WebLink AboutGW1--06053_Well Construction - GW1_20230921 44-ELL CONSTRUCTION RECORD (GW- ) For Internal Use Only: 1.Well_3Cont � ractor Information:ill •tr!rA i Oki 1 ... Wel Contractor Name • FROM TO DESCRIPTION iI • rA ft. a,7.$ ft.3 3 3 s.Gft , 1,I Q ft r NC Well Contractor Certification Number P ti15:OUTER'CASING(ftiniiiiltilVd'sed:ivelli)':OIt7INF2Mifiap'liratiT) - ' • Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. Company Name - 16 INNER'.CASING OR TUBING(geotliermal c16§ed:loop)'- . 2.WellConstructionPermit#: J FROM TO DIAMETER THICKNESS' 1 MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) //ft 6 3 ft ` I/tl in. .C! l`a t��ic i 8y VLl iv `5 -fir ( lf:lee 3.Well Use(check well use): ft. it ;n. ..17.SGRF:ErY.`_ _ L -r_, - -___ _ _._..�`_.- Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL, ❑Agdculfural ❑Municipal/Public ft. ft in. ❑Geothermal(Heating/Cooling Supply) Tiittesidential Water Supply(single) ft ft. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) ;18 GROUT:s'..: i = a, ?' :;ir,: __, r:.- , — __ ❑luigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: O ft. / ft 58 at ert5 t,i t fro vd- to l3�S ❑Monitoring ❑Recovery ft. (� ft I ar!fps ft r ✓"s Injection Well: ft. ' ft. ❑Aquifer Recharge .0 Groundwater Remediation ❑A qurferSto eandRecov ❑Salmi Barrier 1119 SANDIGRAVELPACK•(if:nppliccable);-r.- `..„�•::.- „ .__. ..-.. .__... Recovery tY FROM TO MATERIAL EMPLACEMENT METHOD DAquifer Test ❑Stormwater Drainage ft. ft. ❑Experimental Technology 0 Subsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer ls'20:D1:11:C CLOG(iittirch'hadition`al'sheetaifife`c sirrry)l".. '. r-,; ;i.; • ❑Geothermal(Heating/Cooling Return) ❑ether FROM TO DESCRIPTION(color,hardness,soitlrock type,grain size,etc.) ' (H g (explain under#21 Remarks) D ft. f r Date Well Started A- I.G-�'a 9t I Q I 4.Date Well(s)Completed: g'—OSsa.S Well ID# ,'( -'j 2/ 0 Z ft 3 0 ft G i 4- G` 5a Well[Location: 1,. Phone#:33' tj C-e' - 7 o /6 3j ft. 220 ft k 9tI dcr ild . w a. J•LA.SLa_/f► /t"o t/ eie i3lp,�er.-,i'Gi/ 22 ft. 2tto ft ,sha 5k4s�' SOP' . Facility/Owner Name � �Facility ID#(if applicable) aile ft- 1 7 y it der w it,7L ,-3s 138� Hwy gO/ Vl/,,..e•A1'Vilie, a9iy' ft. 2oo ft. L 15i1d- 4/s. d-'c.'"i3.1 t1471/41. Physical Address,City,and Zip 2q() ft. 3 S-2 ft. citric. Crk S n n i a-e, heed 'A-rL1- +'921LREM:6R7(Sry -. . _ ...__'-'-'`s. x. , i .►`,__4,. ,. ::` .. County Parcel Identification No.(PIN) :'-"( r(f ' + , 1 r-i ' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: S L D , 2023 (if well field,one lat/long is sufficient) `�/' 22.Certification: C f 3 6 Z .a• ! g 4N 2r/ ?le, Z�da w , Pr., 6.Is(are)the well(s): [Permanent or ❑Temporary Signature ofCertified Wel ontractor Date P By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: ❑Yes or in/'0 15A 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 the of this record has been provided to the well owner. repair under#21 remarks section or on the back of this farm. 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 I GW-j is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. dulled t. 24.SUBMITTAL INSTRUCTIONS 9.Totl.itell depth below land surface: 3 fa. (ft.) ---, Farmultiple3vells list all depths ifdifferent(example-3Q200'and 2Qa�1700� Submit this GW-1 within 30 days' well completion per the following: 10.Static water level below top of casing: d t/ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),• • ` If water level is above casing,use"+' Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617 11.Borehole diameter: `� (in.)Bit Off: •I ii 24b.For Injection Wells: Copy to I)WR,Underground Injection Control(IOC) Program,1636 MSC,Raleigh,NC 27699 1636 12.Well construction method: V 0 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 13a.Yield(gpm) I S Method of test: al IP Permit Program,1611 MSC,Raleigh,NC 27699-1611 70% hth Date Site Visited: .? , �-a,3 . 13b.Disinfection type: Amount: 6 OZ Slte Visited By: if Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources t Revise/!/ 6 -2�0�1 a Price:_ rt�� srhuc da 0