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Home My WebLink AboutGW1--07528_Well Construction - GW1_20231120 . . ., . ,.... • .. . ., . . , WELL CONSTRUCTION RECORD (GW-1) . For Internal Use Only:, 1.Well Contractor Information: . 6 -: -. ---- ,sf•.., ,• .,; . .-, 1711 . . . ; . . ..., - ,,Nrcvsi- t0e.t4r.. r.t tei S WATBRSONES-•:_1. -i.-:-..;.aci;.2.-.73.-.723.'.1.TiZ,--7.:-:i..`--...-::::::::.. 2.•=di.--._----."'::::..2_":..:',f'•:-11 : - Well Contractor Name _ '''C'..V, ., . I t141 • FROM it. TO... .f-t.. DESCRIP1110 N ft. .• ft - NC Well Contractor Certification Number • C-.- Yadkin Well Company, Inc. FROM TO DIAMETER iiniiall's):011:LINERVIC THICKNESS MATERIAL - ..,....T-% . ft• ft. in. "." ---) . ' Company Name )13.6aNNER'CASINGDRTUBLNGirgiolliefiiiiireldird;loi -1:'.:13M:..1 •. 2.Well Construction Permit#: I Li_ct 7( S— , FROM TO DIAMETER THICKNESS MATERIAL . List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) f!' 13 ft. I . in. laft. it Pav . - 3.Well Use(check well use): ft ft. Water Supply Well: = . • • -• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ' 0Agricultural OMunicipal/Public .. . ft. ' ft • in. 0 Geothermal(Heating/Cooling Supply) glesidential Water Supply(single) ft. ft in. - Olndustrial/Commercial OResidential WaterSiipply(sliared__) ..:18G11:01JTCLIZ:-_ - _ ..---__ ..-----—-7---- .----:::::__- _----- ----I---:IT;I:Irrigation ,OWells>100,000 GPD : FROM TO .--7-MATERIAL- —IMPLA GIDENERN.A T ME'IHOD.8,AMO....,.. ' Non-Water Supply Well: . • . ' , ft• Hole ,,ri.a,-.5 rrej-zet) , 2 iixa s5 . . OMonitoring ..; .ORecovery. , 3 -ft , 20 ft owocit.,cre,A- rcogv7L3e9 ,Y2 i 30,55 .:Inj .ection.sVell: .. • ••• OAquifer Recharge •OGroundwater Remediation - _. ,,•, •.- .- •i".."19'i:SANDMRAVEIIPACICtifliipliEalile).,...___ -' OAquifer Storage and Recovery O Salinity Barrier . .., FROM TO . MATERIAL , DM:PLACEMENT METHOD' . . . OAquifer Test OStormwaterDraina.ge • :, ' ft. ft • . . . * •--'• OExperimental Technology 0 Subsidence Control ft. - ft '• . OGeothermal(Closed Loop) OTracer .. •• -• !:10iIIRIET:rtiGTOG($ittic-RrlddititidailIfreffif.ifellifily)7==-1..1":.= / • • ' FROM TO • 'DESCRIPTION(calor,hardness,soil/reek type,gr.-4171-512e,etc.) OGeothernaal(Heating/Cooling Return) 00ther(explain under#21 Remarks) . . _ • Date Well Started /0111 1:21: - '' '• 0 Ir. 5 . , Jo; I. - ,d3 ...:le Li i • e 4.Date.iVell(s)Completed:iti1 f 2103 Well ID#114 r'-n 41 , 5 ft SO t ft- rit.jiv"...: > ci,,.. % 4e, 7V,•-•:,;-•• .•. . •-•i . .. ,.-..• '-1.),.. .-'' Phone#:gag_-773,4-114 se,oft. . i(lorg ft ..,.. ' 5a.Well Location: . . - , • . . ..', ,,i i- ,\ c A ,,..I" , - , woos&' ' -C241 ft. - ft. • . . . ., . Facilit:'..nifrner Name r Facility ID#(if applicable) ft. - ft. • '• ' g.,:-;• il i)--1 ) NOV 2 0- Zbg3 __. , ••-.--, . kivetwi4d rl'r ' La4s;4.5--. .49-- q3 • ft. ' •ft. - • ...: . . • • ' - - - .,,,•-: - Physical.kddre.ss,City,and Zip • .'.' AS44.... • ' . ,. I:::::.:3'..)G. .-''• ., . : ' 'Count}, Parcel Identification No.(PIN) OVV , _. . " " ',...----5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - . .' . . . '• -: ....- . : (if well tick!,one lat./long is sufficient) 22.Certification: ., •. . , ':: ... .. • . -.- .„.• 3 N 0/ oi 53 10 31 . o (1,,,, , _A' •:'t,Aje-TCM: . 'A ' 97 , . .,„,-,.. . SignEitire of Cerfified Well Contractor r.. • •:.- ' 6.Is(are)the well(s) i'it'ermanent or OTemporary , .. . .. .. - ' ' By signing this form,.l hereby certify that the we.7(s).was(were)constructed in accordancewith -. f: 7.Is this a repair to an existing well: OYes or o . 15A NCAC 02C.6:100.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 ad!record liar beenProvided to the well owner. ' repair under#21 remarks section or on the back of this form. . V V V. < 23.Site diagram or;additional well details: . 8.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same . You i in may use the back of this page to provide additional well construction info , construction,only 1 GW- is needed..Indicate TOTAL NUMBER of wells . It'ai .., • (add.See Over' Remarks Box).You may also attach additional pages f necessary. chilled\ 11 i 01 ' '•,;,''' : . . ,. - j.4..srmivir- rrA.T.,INSTRUCTIONS CP 9.Total well depth below land surface: i i 0‘ . V Submit this qvv-1,vvithin 30 days of well completion per the following: 00 For multiple wells list all depths Y'different(example-3(200'and 2(g100') . ,.. . „. 24a. i'ai'All Wells: Oriform ginal to Division of Water Resources (DWR), .. 10.Static water level below top of casing: 410 - ,- ft')-. Information Proce.ssing Unit,1617 MSC,Raleigh,NC 27699-1617 . If water level is above casing,are 7-1-" ;,. .. 11 Borehole diameter .ii,, •,,, ..7 6 „ii,Bit off: 57) R,7 gram 0 24b.For Injection Wells:Copy to DWR.,Underground Injection Control(((IC) 02 . :--... .... Pro ,1636 MSC,Raleigh,Nq 27699-1636 . • 12.Well construction method: 61 1 C ' ro 4-,4 eN,. 24c.For Water Supply and Op en.Loop Geothermal Return Wells:Copy co the --.. (i.e.auger,rotary,cable,direct push,etc.)`., i • 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 st) Permit Program,1611 MSC,Raleigh,NC 27699-1611 f- 13a.Yield(gpm) 1 Method of test: 41‘ ?5" Off e , 1 ,. ., 1 _.71 3...-i.3 - • • . 70% hth 9 8 oZ Date Site Visited: a i .1 1 i 5 V 3 13b.Disinfection type: Amount: Site Visited By: ' . ' - I i , • - . f.::, ::::;1:::.:,... Form GW-1 _._North Carotiria,Dele;tria6itt of Environmental Quality-Division of Water Resource Revisect&6-2018 ,•.', • . -•: '....:;.: - '.''.;-:''''.. :-';'..'.''..''''