HomeMy WebLinkAboutGW1--08011_Well Construction - GW1_20231214 . ,
i----------WEL.,,L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contra'i',121.1114,9,J r-nal lion:
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- _ FROM TO DESCRLPTION
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NC Well Contractor CortiEcation Number "1:15.6UTER.CSNG(fefiiitiltiaild'ialby.oRLINKEV.
•. Yadkin Well Company, Inc. PROM/ TO, DIAMETER. TECICKIESS:. 1 MAT7
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Company tqatot. _ . [ .
', '-;•':1:6:' s;CASkG.OR (a"elitlier-m-ar-eloked;liiii-P)LLI
': • 2.Well Constraction Permit 4/: _ Z RS .5-1 ( _ _ FROM _ TO DIAMETER THICKNESS.' 11-CATiiitI—AL 7. Mr
List allapplicablewell construttion permits(i.e.UIC Comity,State,Variance,etc) 4/ft. __ft to, liv ' 4.1.50 . ces (
( I, i... . ft. in.
3:Well Use(check well Use) 1I / C --: - • CA-- - I Line' '..•__:,..1_..= .„1:221=.::::_:_-_,Lli.2_:_-___-:-..=--.T-2`2.72-:-.-''''•'-,
•Witter Supply Welk' FRO TO DIAMETER. SLOT SIZE THICKNF,S MATERIAL g-
DAgricultural DMutiidipal/Public I it., ft
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OGeothermal(Heating/Cooling Supply) aliesidentialWat&Supply(single) - ft, r , ft. , in., '
• DIndUstrial/Commemial EIResidential Water Simply(shared) i::-.3.8-:GRour,--,_- :._:-•__-_,:.....--=----,-:- --._-_-_-: - i- --. - • •• '1
. FROM TO . MATERIAL EMPLACEMENTMEMEIOD&AiiOillii
. . Olnigation__ OWells 100,000 GPD .
Non-Water Supply Wellt : . el fi.. :3,„# fL 13 arps arc..( / 1 i leis
. ommitoti,g. DRecov, . ft. ' ft.
Injection.Well: - ft. ft. / /
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DAquifer Recharge .0Groundwater ReMediation
1:19`.NAVVIGRAVEXPACKatifaliealneIL
13Aquifer Storage and-R:eCovery ElSalinity.Barrier" FROM. TO, MATERIAL, EMPLA 1,151 151.METHOD • '- ..'
. :DAqUifer Test OStorrawater Drainage
(::,... ( ff.
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ElExperixeciatal Technology OSubsidence Control ft. ft. , . ,
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0 Geothermal(Closed Loop) OTiacer [20i- - 1 G' OG(ittitellTidditiiiiiiriliiiiiiifileless-art11__1_ .....,......-....____ - •.'
TO' DESCRIPTION(color,hardness,soll/rbak—typ-C:grain size,ate.):
ElGeothrxrcal(Heating/Cooling Return) Itiether(explain-tinder#21 RemarksY -FROM . _ .•.
Date Well Started 11- fr ..13 .0 ft.. ..,.. 1,0 ft. So ii,/
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, . ,4.Date Well(s)Completed 1 I-to-.a) Well Dm A-, P .”3 . to. fe• co ft.
.2regt,)„,,fre Oct&
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, Sa.Vell Location: - Photte#:,r3$-}W/1 0 S 457 , go, f.t. . I,10 ft. 6 oft. 5,f,„e........ geaft. - '
0 4 Ltsli Adze ihoki4 ,- ....
it ft. -I _ a ir— , .
_ gi4 fl,C1* /010..". }'A IF 5 iKel- w en toe-itil .
Facility/OwbetName Fatality M#(lEappliCable) _ fr."' 160 ft. Viol'416, you._ .
A fra ' . - , • ,..•
40 71.• r _ti/l.ir e Ail(.71.,. A tex..1,1 1?5,, de ou'. .1-icyft. i 15,n4.; 8$4, ;root,' kera - -
,.- PhysicalAddress,City,and Zip 1 ft ! -
t4e'4(tP05 462"-ft. 5("•*---. 1-efrY),.. ,•••-)! 040--
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14.4„hti494. - -. __ . ca . . _
Cott*: Parcel IdentifitiouNci.(PlIly ' : Y. _c•fir .in wo:se
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.• V van, 1,,,,,,4 ,„,?: Al L.1,:i• :, '
• Sb.Latitude and longitude in degrees/minutes/seconds or dedina.l degrees: . . _ _.. . _
(if well field,one lat/long it Sufficient) 22.Certifidation: DEC I 42023 . .
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, 36 D q, V5oi . N, 1 31$;., i 1 4,4/ W -,,--5 -"•"eistr._ ,
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i 6.1s(rire)the well(s): PerManent Or- OTemporary Sigature of Certified Well Contractor Bate k.,..,_.:t...»..:.) • •
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By Signing this form,Thereby certViliat thewell(s),was(were)constructed in accordancewith
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1,3.• ID this.a repair to an dialing well': ElYea or ?(No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction-Standards and that a cop);--.•'' '-'..'
gth is is a repair,j1lIout known well construction inforMaticin w explain•the nature of the of this record has beenprovIded to the well owner.
„ repair under 4121 remarks section or on the back of this form
-. 23.Site diagram or additional well details:
You may use the back of this page to provide additional-well construction info ,--:- -'-'•••"
8:For Geoprobe/DPT Or Closed-Loop deotlierinal Wells having the setae
constiuclithi,only 1 GW-I as needed. Indicate TOTAL NUMBER of wells- (add"See-Over'in Remarks Box):You may also attach additional pages if nedessary.: .:,.•,,,.';;:f,
drilled: I
. 24.SUBMITTAL INSTRUCTIONS
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.. 9.Total well depth below land surface: SO 1.. (ft)
iis GW4,within 30 days of well completion per the following:., , •'i A . '1 Air thuhiple wells list alldepths if different(exarnple 3@200'and 2@,100) Submit this
., . 24a: For'All Wells: Original form to Division of Water Resoureei,
I&Static Water levellielow top of casing: 1.06, (ft.)
(DWR)
Infonntation Processing Unit,161714SC,Raleigh,NC 2769,0-1617 '• --'" '' • •
If water level is above casing,use"+"
, 24b.For Intettion'Wells:COrzi,to DW1t,Underground Injection:Contro1:duci
,, 11.Borehole diameter:, . . 4. . on..)Bit Off:.6 III
-. - Frog:rani,1636 MSC,Raleigh;NC 27699-1636, `- , ,',. ; ' :,, ,•:•, ...-,;':',:•-• . '''-Ob. •
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It.Well Construction Method: A:t' - • --... 24c.For Water Supply and Open Loop Geothermal Return Wells Copy to the cp.
(i.e.auger,talky,cable;&act 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:Copy to-DWR;cpPevA
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13a Yield(gpmy Method of test ailk Permit Piogram„1611 MSC,Raleigh,NC V69971611 . ., .' . y•-'-, -,..•
• . .fr : , . , • .-- •' - •
70% hth, • Date Site ViSited: 3--/.57.—Z3 -- • ,
' . 13b.Disinfection type __ . Amount: Cr oz Site Welted BY: VAS, ' : •--'..: -• .. ,....i::•• 2' . : '
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orth Carolina Department of Environmental Quality-Division of Water Resources- : . ' , .: : .' ... i ' Revised 6-6-2018
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