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Home My WebLink AboutGW1--06966_Well Construction - GW1_20231027 �v WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: �G • 1.Well Contractor Information: 1 1 •„)t y1 ( 1-I,14 U"aa rwATEZi-zoNES 1 7::: :33-7. f,"._.5_= .;_.f_:'?. i.2iLL:�.-.-< Well Contractor Name FRO TO . - DESCRIPTION ' 'laid - Aaft. ��'tt it Se ,c peJ- M h- o-r�j�►-1, j.3ofr• :a-3 I ft Sri 5V0a- -1 ►. 1 NC Well Contractor Certification Number . Cl� ;.15 OIJTERUASTNG(fo4:miilt aiil ieni):ORIZNER•(ifa'linable)'%�' .�w 1::_ZI Yadkin Well Company, Inc. FROM TO DIAME THICKNESS/ MAAL fr. �t fn S CompanyName 16.- 'CASING:OR.TUBING('e'othafi clo—id4i)c.�` ,..,.. 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(r.e.UIC,County,State,Variance,eta) ..# ft z t /1,� 111.1 f S 5f r•al FG 3.Well Use(check well use): ft ft • in. ^/ -___ -( Water Supply Well: • 37:SCRFiEI7: `��__,__—__.._ __.�_— j___ -.�_. FROM TO DIAMETER SLOT SIZE T711 S MATERIAL ❑Agricultural ❑Municipal/Public ft in. ❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft rft /in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 7, -'" =_ _. —_- �------- =-, Ohrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT Non-Water Supply Well: 0 ft at ft. 6(h i••� S 1?ly.bl / r i )44 S ❑Monitoring ❑Recovery ft / ft 1P' Injection Well: /ft ft. f ❑Aquifer Recharge ❑Groundwater Remediation i _ _19•:SAND/GRAVVr PACK'(if apphcable)•T.. ._w- =i... _— --' . . ❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLA.ia5 ra METHOD ❑Aquifer Test ❑Stormwater Drainage t it ❑Experimental Technology ❑Subsidence Control • ft. ft OGeothermal(Closed Loop) ❑Tracer :;20: R1T,LTNGrOG•(ittiicliadditional'sheetiifnecessaiy)' ' -_._--==. ❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness saWroek type Brain size etc) Date Well Started`0-to ..aq 1 0 ft 1 I i ft S z a Q 4.Date Wells)Completed: 10-12-2), Well re#A/4 P r 23 (,it. 20 Lift it'L h . Phone#:S. S- 6l 1 f643 - 5a.Well Location: q/ft 1o,i ft tM !v , d fort, Yt9G 4,vasl.y 1✓L►' r�5t-a 6l d-.-. � f�y Pad7 ft ft Fatlity/OwnerName.. . d Facility 1D#(if applicable) ft ft -.� S.' .' r .' p. 1� �i i 9 C ypr�.ss L 1 �.,egt�it ft ft OCT 2 7 2'J23 Physical•Address,City,,and Zip ft ft . A1 el"X ejl'! i(7{,V 1 J,,L 5 1•.?.1rr::R lICS'.-./_--.y..)a---. ---.. ,•:.-._i ,, 5 ^1;s" _�..1::1C ___---`— - County - Parcel Identification No.(PIN) �� g� r r++ ? �V 4itf 5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: • Si "- CAr4- j r,, (if well field,one lat/long is sufficient) 22.Certification: " , ° k . 31° • 'J 11'B i d® ?N Ft 306g . w 6.Is(are)the well(s): vsi'ermanent or OTemporary Signature of Certified Well Contractor ate 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: DYes or Ato 15ANCAC 02C.0100 or 15A 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 form. 23.Site diagram or additional well details:- 5 8.For Geoprobe/DPT.or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional*ell construction info construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: t24.SUBMITTAL INSTRUCTIONS/ — 9.Total well depth below land surface: 4 6a (R') Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3(a)200'and 2®100) t, 24a. For All Wells: Original form to Division of Water Resources (DWR), (O 10.Static water level below top of casing: v (ft.) Information 'rocessing Unit, MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" 11.Borehole diameter: CO (in,)Bit Off: ®® 1 3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) E l'J` Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: (/ G,a Or r a 4-fear®. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (i.e.auger,rotary,cable,direct push,etc.) f county environmental health department of the county where installed r FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA\ t Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) f.•-' Method of test: C l 4 is 1 r . C.)a o Date Site Visited: /i 7/07 3 •� . 13b.Disinfection type: 7D�o hth Amount: @ Oz Site Visited By: I 6 ,- Form GW-1 __r North Carolina Department of Environmental Quality-Division of Water Resources: Revised 6-6-2018 .. ----1