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Home My WebLink AboutGW1--02306_Well Construction - GW1_20240410 WELL CONSTRUCTION RECORD(GOV-1) For Internal Use Only: 1.Well Contractor Information: Jektal,e3 I,'1aa0 0.4•::WilyZONESy.: . i`'i;":l t.1,22u:. . .;..�.u,:.. .• . ... � Well ConhactorName T F(R�OM TO DESCRIPTION' �" ft. It ft �f'(Yn4,Vi YLecce,..„. ' J✓�'t ri I*i s A- • 4 YC,,ft. gigft f ,4f�� p q NC Well Contractor Certification Number 7 ) �'1 a�l "~r `t Q +- „15:OIITER'CASING'(foe'm`riliaiiied:wells)`:OR'LINFR;(if,'lii.li alileJJ;;t.� _::: Yadkin Well Company, inc. FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. Company Name r-- >16 1NNER GASING:ORTIIBING(geotlierinil:closed=l6op): :""�77,*-72--.:, .;,::-_ r-° 2.Well Construction Permit#: ��J FROM TO DIAMETER THICKNESS MATERIAL. List all applicable well construction permits(i.e.UIC,Carty,Slate,Variance,etc.) •,f , ft. gj /' ft /'.I ry ! in. (5 2' '�J��/, 3.Well Use(check well use): ft "S J� ft i0 !� ] in. l/ r (/`� p+ Water Supply Well: a�"L-TS.-GxiLFL " - - --- FROM TO DIAMETER SLOT SIZE THi ESS MAT ❑Agricultural ❑Municipal/Public ft in. [a// ❑Geothermal(Heating/Cooling Supply) esidenfial Water Supply(single) ft. ft. (in. ❑lndustrial/Commercial, _ ❑Residential Water Supply(shared) 48:; -oUTtt:".r": ' r,,_ __ _,..: ❑Irrigation ❑Wells>100,000 GPD FROM " TO - MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ® ft. r) 0- ft. �/j I t p' C' 6/wit/CI 4i4 it/C/ J'f /. �.7 (A'l i J l7 l ❑Monitoring' .❑Recovery ft. ft. Injection Well: 3,\ ft. ft. i- ❑Aquifer Recharge ❑GroundwaterRemediation _ il19 SAND/GRAVET PA:Cl of Fatale '.�'�„_.`____.._,"�M",- ...:____71:7== ❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO ME THOD' EMMA. ❑Aquifer Test. ❑Stormwater Drainage ft. / ft. ❑Experimental Technology OSubsidence Control ft. 1 ft ❑Geothermal(Closed Loop) ❑Tracer 20 DRIG"LINGI:OG`(n`tfactiadditional'aLee`tiff.necessary);==-"—" =- • ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soll/roek type grain size, • Date Well Started L f_i- 2 CI ii 0 ft .S : 4.Date Well(s)Completed L(' 2` A�1.t Well ID#s`+ P" l,7 @ fr. I/�/,� ft G� �[r /Txrt. I„ �1 . Sa Well Location: Phone#: £Zg .rc7 a/'-00 e I I/i ft ` i. ft .,„ 5Vtr !neva, Fl b[f"b /F`/iAkt i_[ S ft. t 5 _ ft I[wl /C?rti.h v x - 1/-c.y 51 -. • , Facility/OwnerName (� Facility ID®#(if applicable) t9. `2� ITS 2., ft' L 2 ft' p,{,,r- 9,Sy. Wei ' ' IC+ i� /'eitrAi0 .I gel. !/1. a s >�ls • 3l<A15..f L eij-£t. �t7 Z-ft ' LL'�t��-rl9kir 11.112 .. Physical Address,City,and Zip ft. ft. 7 - - County Parcel Identification No.(PIN) k.,`� �-'a V` +' ry , 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G A IC R 1 0 2024 , (if well field,one 1at/long is sufficient) 22.Certification: y 6.Is(are)the well(s): j�Peis nanent or ❑Temporary Signature of Certified Well Contractor Date * 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: ❑Yes or NNo 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy • If this is a repair,fill out]mown well construction information and explain the nature of the of this record has been provided to the well owner. repair under 421 remarks section or on the back of this form. 6 "' 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 constnlction info construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary. drilled 24.SUBMITTAL INSTRUCTIONS - 9.Total well depth below Iand surface: ;!B Y./ (ft.) Submit this GW-I within 30 days of well completion per the following: .FormultiplewellslistalldepthsIfdifferent(example-3(200'and2@I00) _ • ? 24a. For All Wells: Original form'to Division of Water Resources (DWR), 1 10.Static water level below top of casing: 13 O (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 "� - If Water,level is above casing,use"+" 1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) IL Borehole diameter: (in,)tilt Off: 5,77 S Program,1636 MSC,Raleigh,NC 27699-1636 - ° 12.Well construction method: Air YQ46y1 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (Le.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 13a.Yield(gpm) -S Method of test: {V Permit Program,1611 MSC,Raleigh,NC 27699-1611 o Date Site Visited: S'1 al 1 it, 3 . 13b.Disinfection type: 70/o hth Amount: ( 2.. OZ Site Visited By: AI 4 4/7 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 Price: Su, Ce/1eiru.C) ,