HomeMy WebLinkAboutGW1--01739_Well Construction - GW1_20240315 R/'
ViiiLL CONSTRUCTION RECORD (GW-11 For Internal Use Only: :06`n
), - 1.Well Contract' im "aon: :01 Pq ' .
Well Contra Name FROM TO .•' DESCRIPTION
3 - 1 r'9 1010 f' TO oo ft
ft. ,. V ft I. I
NC Well Contractor Certification Number 15::OU1T:tt'CliSING f6'r`miiltrcased:i eIli':ORLISTER(ifa'"lic`alile•- ::
Yadkin Well Company, Inc. ( ) )� �J
FROM TO DIA➢LI.TER TffiCKNE4
ft. lc-
_lily '�_`
Company Name _�- :,
a®� j A1.6 IlYNEIt. •.'I
:OR'.T[lBEIG(eotliermal clakT-Iiiii0 -: - :...,•_.:.�
2.Well Construction Permit#: "'� FROM O . DIAMETER THICIaN:FSS MATERIAL
List all applicable well construction permits a.e.U1C,County,Stare,Variance,etc.) ft. in- �-
3.Well Use(check well use): it � in
Water Supply Well: t17 SCREE .+:'.L�=' --.:- �--_:_..:__'__._._--- --,---- - _ _:-
y FROM 'TO-----....._DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipai/Public ft ft -'-•tr2-- —
OGeothernial(Heating/Cooling Supply) ❑Residential Water Supply(single) ft it:-. m.
❑Industrial/Commercial dential Water Supply(shared) .;in G`ROUT_:'."_. :- ..., - -- ` " _, _J
-'-- ❑lnigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft• "��
❑Monitoring DRecovery - ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑A urferStora Storage ❑Salmi Barrier i.19:SAD/GRAVFLPACK{ifspplicable) _:_�":_ •=_-�-_ -.1_ -,
q g Recovery tY PROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ,ft
❑Experimental Technology ❑Subsidence Control ft ,
❑Geothermal(Closed Loop) ❑Tracer !.•20:DRILLINGIOG`(dtfa'cliaddiflorial-slie"etaif,necnsaiy),..'.__ --:._
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❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,haraae�,sotvrock type,grin size etc.)
Date Well Started -'.6'-1-t ft
.
4.Date Well(s)Completed: ?a-1--xq Well m#AA o Or3 xft l f1q ft-, a'y fn1114
5a Well Locafionj:� Phone#: q/0.•I1 S19z ft ft
t t 1 1.,D-Arc 1 - ft, ft _ `
y-
Facility/OwnerName Facility]D#(if applicable) ft' ft _.. i '1`) G y •
2 o 1 . ,2 av tr i o k Rd lAktradowl k ft. ft �- 'Li /f T
Physical Address,City,and Zip ft. ft '. M,4 N j.5 2 1 A '
h 3 Aiticsr, ---� , _ .o .t-mow �._ _
County Parcel Identification No.(PIN) lIPlite is /Ci l I r.,i� 'f.'C'''....9sicc 1,
i ......rWI;tOC, 'a ...AO
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - '(if well fiie�lpd,,r one 1at/long is sufficient) 22.Certification: ry Q�
3C -I65 N 3i/�/ 9617c W 0 i 4 6 6-j c... e -�1 l� -( •
6.Is(are)the well(s):• 'ermanent or ❑Temporary Signature of Certified Well Contractor Date
Dri Q I .elfsLt 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: Xes or I JNo 15A NCAC 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 aphis form. i
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 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yon may also attach additional pages if necessary.• .Q
drilled: - /�Q 24.SUBMITTAL INSTRUCTIONS 9)
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9.Total well depth 11 land surface: V J N.
(ft) Submit this GW4 within 30 days of well completion per the following:
For multiple-wells list all depths if different(example-3@�00 and 2(a)100)
tt' ' 2 4a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Q 0 (ft.) Information Processing Unit,1-617 MSC,Raleigh,NC:27699-1617
If water level is above casing,use"+"
11.Borehole diameter (in.)Bit Off:5-a 0 24b.For Injection-Wells:Copy to DWR,Underground Injection Control'(IUC) L
Program,1636 MSC,Raleigh,NC 27699-1636 -',
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12.Well construction method: A I f - (a9+eiPjr 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the• ..
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the bounty where installed
FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CC4c4
t Permit Program,1611 MSC,Raleigh,NC 27699-1611 �(J
13a.Yield(gpm) 3 Method of test:_r Al I
70% hth Date Site Visited: e
� -
13b.Disinfection type: Amouat: ,)) OZ Site Visited By: i I '0\ l�� _(C-`'
J � I A co c.
Form GW-1 a _ _ 1 _ North Carolina Department of 1nnvrronmental Quality-Division of Water Resources J\ � S& evised 6-6-2018
_ Price - --- -- - 9 I� ��,��o
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