HomeMy WebLinkAboutGW1--08005_Well Construction - GW1_20231214 `"' 3
'.1r�)L CONSTRUCTION RECORD(GW-1) For Internal Use Only: O
• 1.Well Contractor Information: y
Oi4i �`1n t1 a h']4WATEA ON legit :'' r'=4 lat;,
li:: .',..-,-P,17'l;-'.;.;..._:..__;i..l-: „;,
Well ContractorNam1 FROM TiO� DESCRIPTION .^
9 S'7 2 .4 /1�® fL - 41)-) ftt
NC Well Contractor Certification Number Company, Inc. (it15.OU113t"CASING'for inirlti=c"ased:weIIa:O1tI3NER ifa'7lcable: :.
Yadkin Well ) ( p )
FROM TO DIAMETER THICKNESS MATERIAL
ft• ft in.
CompanyName r .:-, ..i
�a e16!INNERCASING ORTQBTNG({eotSermal closed:loop)' `��-`4 :._-L:v
2.Well Construction Permit 10: L()(r a'v FROM TO DIAMETER - 1BICKNESS MATERIAL
List all applicable well construction permits(r a IIIC Courtly State,Variance.etc.) 44 ft 1,3 ft 6// J
"in• t.'0 . 0 1 Pee(
3.Well Use(check well use): it vs ft in
Water Supply Well: s7o TO� M DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural D�M/uunicipal/Public ft. ft . in.
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❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft, ft. in. ..
❑Industrial/Commercial ❑Residential Water Supply(shared) _.. _-_�_--- __- _
. ;=18:GROUT,.;.—__ '
❑Inigation ❑Wells>100,000 GPD FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. /e , ft /.1 " �i it)eyed .
❑Monitorin ❑Recov ft 7 . ft .
H
Injection Well: �� ft. ' �® ft j 104 f(°� Cy�e+q �^� .
❑Aquifer Recharge ❑GroundwaterRemediation 7 I _T_ _
f:19.SAND/G RAVELPACK'(if`applicable)'=_ ..�. _. = -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
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❑Experimental Technology ❑Subsidence Control . ft. ft.
❑Geothermal(Closed Loop) OTracer- C-2ti 31R7>YSNGI:OG(attacli`adilitionalsheet's:iEriece;satip)_':-----17.-7'— :::::_-_
❑Geothermal(Heating/Cooling Return) ❑Other(explainunder#21Remarks) FROM TO DESCRIPTION(color,hardness soillraektype grain size,etc.)
Date Well Started 9/-1-9-4 /� 0 ft 5s i.ft. 'oaZ
4.Date Well(s)Completed: /r�-(` Li) WelllD# A4L 3 9,5 5LI( ft roe-'it nel et,4471,6es, 4:1Ts•'
Sa We]1Location: •Phone#: .S 36-5241-Oq9 it- ft. ' ft _ �a
ALeS le/iowa le l ft. ft. . . k. --'7 f`F:
Facility/Owner Name Facility Mt/(if applicable) ft ft I ,l '—)
ft. ft. "�� y • L�cJ
'71 C AiOkktvarrnnCp'cei�t (Jv, Mthtcvia0 1af11 .
Physical Address,City,and Zip e065� ft. ft I i11� 1 �' _ -.� ij i,; .
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- W •, /ke 172I.RRMARKRf w_.. .......;t. ti �-- -'• ';..J:._-.—.
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County - Parcel IdrntIfication No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
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(if well field,one lat/long is sufficient) 22.Certification: '
6.Is(are)the Well(s): E4 ermanent ,or OTemporary Sigea ofCertifi ell Contrac or Date
By signing this form,Ihereby certrfy that the Well(s)was(were)constructed in accordance with C
7.Is this a repair to an existing well: ❑Yes 'or Inn< 15ANCAC 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-ve11 owner
repair under#21 remarks section or on the back of this form. . CY)
23.Site diagram or additional well details: 41'
8.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
(add'See Over'in Remarlmn Box).You may also attach additional pages if necessary.
construction,only 1 FrW 1 is needed. Indicate TOTAL NUMBER of wells +�
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Cy®2,- (ft.) Submit this GR!-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100)
I' 24a. For All Wells: Original form to Division of Water Resources (DWR), E
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
24b•For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)Bit Off: a�.�� Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 4...,- R .ir,1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Cop to DWR,CCPCUA 01
B Permit Program,1611 MSC,Raleigh,NC 27699-1611 &IA"
(.13a•Yield(gpm) +a.!0 Method of test: /— L
e c hthDate Site Visited: 9- �;�7
13b.Disinfection type: 70�c Amount: 13 OZ Site Visited By: Co 74/1 I !" Cr•4 -JL -?h�,,,oie i
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018