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Home My WebLink AboutGW1--06980_Well Construction - GW1_20231027 r a C 'Eii L CONSTRUCTION RECORD (GW-1) For Internal Use Only: C. • 1.Well Contractor Information: pp dd a,� .. aw47.4,'lion 0 e�1 %i4:;WATF ZONES�..__.;:y;:w?S.i>:;: .•�a".'"'_.:;.•'_gig,:..::` �;__.-,..., ,' - Well Contractor e FROM1 rt TO ft ➢ESCRIPTIOON'dr .1i ,f4 4�k C� N jf V 3 (t((��///o I , ft. it 7). ft to t NC Well Contractor Certification Number 115::Ou'1'att:CASING'(f6i'mnffi;eeied;. )'ORIANBR(if if li able)7-' .".t 4' _: Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS ] MATERIAL ft. ft in. Company Name411 AR>, ':16111MR"CASING:OR'.TOBING;(Reotlie=maiclosed"Ioo 2.Well Construction Permit#: ,3 .7 4i q 3 FROM TO , DIAMETER , THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) #I ft. /2 ft /�v•X 5 'l r - _� 1 3.Well Use(check well use): fti rft. Q in. P� r Water Supply Well: FROM TO `= DIAMETER SLOT SIZE ^THICKNESS MATERIAL,.n`i: ❑Agricultural ❑Municipal/Public ft ft in. ❑Geothermal(Heating/Cooling Supply) ZI.l esidential Water Supply(single) ft ft in. ❑Industrial/Cammercial ❑Residential Water Supply(shared) ::,18 GROUT_.:r = _: - -- _T -- ----- ❑Irrigation ❑Wells>100,000 GPD FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ® ft a ft' j41 0 1 r poi eel ❑Monitoring ❑Recovery. ft 9-S`lit p�ry'��Injection Well: ft ft i d 6 Love,' ❑Aquifer Recharge .DGroundwater Remediation t.9:6A1ND%GR AVEI PACK£'(itap-fi icalik) ::'---.- - -- ----.::_-.:'2=?' : . DAquifer Storage and Recovery OSalinity Barrier FROM TO _ MATERIAL ENLPLA CEMENT METHOD ' ' ❑Aquifer Test ❑StormwaterDrainage ft. ft. _ ❑Experimental Technology ❑Subsidence Control ft. ft 0 Geothermal(Closed Loop) ❑Tracer ll20:DRILY:INGI:oG.(attiaiiddiflonalsheetiifneeneary)=.� '�Y_�. ❑Geothermal(Heating/Cooling Return) III Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillroek type,grata size etc.) Date Well Started 1-, s-®/),cy...s'' ', ® ft �5 €r• (5'0,1. JRsuLks 4.Date Well(s)Completed: /0 s7- ,�''Well'IDgir --1 l9 (BS® ft. g ,®oft ,5 �� e® 14 Sa Well Locatio Phone#: St• g-'7 73-3$ +g ft ft /r� 4a (e-( it ft Facility/Owner Name Facility ION(if applicable) ft, ft. _ Cl1 g f feui'u f�6'01 J erte Co- ft 1." R:a .:.i \r'G�:. Physical Address,City,and Zip ft. ft (�T (�i )I, �21RRM&RKC ��_ _.:..�_.__».� _._.-f.-�._^-O-l�. {_._� _�-O Z�:�� County b/ / Parcel Identification No.(PIN) Ifl�,;rr". ';: i1 P!'•'•.:-T/ .m I it+' ' 11r� t1C.: e'Y ll J'-1L'YS 513.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lathong is sufficient) 22.Certification: 11 6.Is(are)the well(s): I3Permanent or OTemporary Si:. of C '+Well Contractor Date By signing this form,'hereby certify that the wells)was(were)constructed in accordance with 7.Is this a repair to,an existing well: ❑Yes or lItt1V o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,full out known well construction information and esplain 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: 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 OW-1 isneeded. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: / 24.SUBMTITAL INSTRUCTIONS 01 04 • 9 ° O 9.Total well depth below land surface: (ft) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3@200'and 2Ql00) 10.Static water level below top of casing: �°e'�' (ft.) Information For All Wells: Original form to Division of Water Resources (DWR), Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use•'+" i 11.Borehole diameter: 6 (in,)Bit Off: 6.i to® 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) /� Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: /41'P r&I PP 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the o (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 w Permit Program,1611 MSC,Raleigh,NC 27699-1611 no ry p r ri, L 13a.Yield(gpm) K'✓ Method of test: �o® whitey 0 Date Site Visited: 7-1/ ''z-3 ,`to s�I.f� 13b.Disinfection type: 70 o huh Amount: 4.7 OZ Site Visited By: D 3 I. L.ft44(e4 Gs.,-1r-ac,4 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018