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Home My WebLink AboutGW1--03626_Well Construction - GW1_20240613 a WELL CONSTRUCTION RECORD (GW-1' For Internal Use Only: 1.Well Contractor Information: I o JGrnt5 HA( k519i WATFd2ZONES'� ;S Well C ntractor Name F9 7 ft.ROM TO ft Shioe . � /1 ( /+� � 16 �. `t ! Y7 IArYK Q J `�' ft • ft C/6 NC Well Contractor Certification Number 0 i:15:-OU1ER' ING`(ftii mulli;e sed'welts):OR t ."Orilp"liatilef Yadkin Well Company, Inc. FROM D,I4ETER :i. ' S l{ MATERIAL ft ft / in. I / CO Company Name [ 111 16' CASING'ORauBING1W t5er'mal elated=loop)' •.'/ 2.Well Construction Permit#: /J 7 / / FROM TO . 1 DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.ee UIC,County,State, Variance,etc) --t- I� ft /3 ft e,1 2 ( $. t2 f JOL/(j 3.Well Use(check well use): 1 1 ft. Y1 it If/ — J in. —i Water Supply Well: LIP. I .:... . .. . ....:`. FROrr TO Di AM SLOT S THI S MATF 1Ai. ❑Agricultural ❑Municipal/Public ft ft. in. ❑Geothermal(Fleating/Cooling Supply) presidential Water Supply(single) ft ( ft. in. ❑lndushiaUCommercial ❑Residential Water Supply(shared) 18:"•GROUT..': .'. ❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENrMETHOD&LAMOUNT Non-Water Supply Well: ) ft. 2 6 ft 0 Gl,1 es G,y.tea, / 13 L jc ❑Monitoring DRecovery ft. ft �I Injection Well: ft. ft DAquifer Recharge _❑Groundwater Remediation ;.19 SAND7GRAA YACR(if applicabI ❑Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL EMPLA METHOD . ❑Aquifer Test ❑StormwaterDrainage ft ft / ❑Experimental Technology ❑Subsidence Control ft ft / ❑Geothermal(Closed Loop) ❑Tracer 20.DRIM GIOG attiich idditiuuil sheets if necees-.. . ' .. ( may)•''. .': ...:.;. . ❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) TO DESCSi1P^.TON(color,hardness,sort rock type grain size,etc.) Date Well Started s 2 S 4 0y v ft .)C , t 4.Date Well(s)Completed: r�"'6 Well ID# AA Q- :5- 0 ft Cr ft k—Yee ft4. 5a.WellLocation: hone#: 4Ic(- 7Cj _ 1c(,t qQ ft. 2 ?W 1,34 Lfisir V 'c_ So ic-l- c.kar, (M;k(.,) 10710P 'it,yft. '30zf. d frock. hiiij/Se — Facility/Owner Name Facility ID#(if applicable) ft- ft VJ )4 ieI L.1i_Ci 1)r ,,,,,ttv,ftn led- NC ft. ft Physical Address,City,and Zip ,4I 1 ft ft l5 IN ii.. '.21?"REMAIIICS..` .. t ,,., . County Parcel Identification No.(PIN) — C "'N 1 3 2024 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -- (if well field,one latilong is sufficient) 22.Certification: r'-rf c-,1 U• 3Ci r Li, 769 N K 1 , .3. �5- w -- nrr..,sc:: .s-ij-a/ 6.Is(are)the well(s): ermanent or ❑Temporary Signature o ertifie ell Con ctnr Date By signing this forrn,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: DYes or Va ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out blown well construction information and explain the nature of the of this record has been provided to the well owner. repair under#21 remark section or on the back of this form. 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•n provide additional well construction 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. cji dolled: 1 24.SUBMITTAL INSTRUCTIONS rt n . 9.Total well depth below land surface: ✓d (ft.) CD Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3@200'anal2Q100) fj) o 24a. For All Wells: Original form to Division of Water Resources (DWR), 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"+" 11.Borehole diameter: (in.)Bit Off: (� ,0 !3 24b.For Injection Wells: Copy to.DWR,Underground Injection Control(IUC) 7 program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: rOfMy 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 county where installed FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA 13a.Yield(gpm) 6. Method of test: r6iitti Permit Program,1611 MSC,Raleigh,NC 27 699-1 6 1 1 o Date Site Visited: I Z ' / — 2 ,S 13b.Disinfection type: 70/0 hth Amount: OZ I Site Visited By: Ai 6 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 Price: