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Home My WebLink AboutGW1--05463_Well Construction - GW1_20240912 WELL CONSTRUCTION RECORD(GW-1' For Internal Use Only: 1.Well Contractor Information: • 3errci fA5 .5.:4:WATWZO Mgt'.`- .., r. uw• �..' , Well Contractor Name FROM TO .• DESCRIPTION a Lt s-4 14 ft. +ac 0 ft. 4( cpoHi • V NC Well Contractor Certification Number 7.:15°OIITEI;:G-''e+iSIPIG`(fo%`mnlf cosed►lTv�lelIssTORTANER;(rt s"li lef`;;-';7:`•:1: ... Cobb Yadkin Weil Company, Inc. " - PROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. Company Name `' �afi.ry� n• + ,i� ?.16'1NNk12;C9S'IIVG'OR��IIBIlYG:�eotIi"ermal`clo'se3loo�='•�:.i:-.;!!ii,.:.•.. r-s #: d,f 1p ' 2.Well Construction Permit ;FROM TO . DIAMETER THICRNE,Ss , MATERIAL fist all applicable well construction permits(.e.UIC,County,State,Variance,eta) ? ft l 1 b ft G vh( 'n- s 0 a9.1 r v-c_ 3.Well Use(check well use): 't':: ft ft in. Water Supply Well: :f , i r ,+,r`J7•SCR> s1,Y�:: �.':: ;. 1::;::%.... :::,"--�-- :.•'„f . '.,`•i ._: ';, �FR0r4I TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL • ❑Agricultural ❑Municipal/Public. : fit ft in. ❑Geothermal(Heating/Cooling Supply) ,j residential Water Supply(single) ft ft in. • ❑lndustriallCommercial ❑Residential Water-Supply(shared) :• ,h•-- . -, -. - S fAtt:.VA013T-f;:..:.t..._w.:-.4..,. "L.:�i1'.,t:.•ral.c ..- ,:i.•�)it:.: .. iti.a «?sue..: { , ., ❑Irrigation `` ❑Wells>100,000 GPD FROM TO •MATERIAL EMPLACEMENT METROD it,AMOUNT Non-Water Supply Well: 0 ft 3 ft able Plug Num.! • 3 J , • ❑Monitoring - ❑Recovery . . 3 ft. e)3 ft Cywe.k Greal Puri •el 31� injection Well: - . fit. fit • '• ❑Aquifer Recharge ❑Groundwater Remediation - , Jr19:.SAND761a IIzP,AGE(if npplicable)�ci: `:................................'::°;.-_. ❑Aquifer Storage andRecovery ❑SslinityBamer • FROM TO MATERIAL EMPLACEMENT METHOD D - • ❑Aquifer Test ❑Stounwater Drainage ;5. .•- ft ft , • ['Experimental Technology ❑Subsidence Control :.r{ ft. ft . DGeothermal(Closed Loop) OTracer ':20:DRTLttINPIGI;OG(3ttac]e.i ditlek Tsfie'ets'ifriec`essar`y)? `;' ' ,_-. s . .. `DGeothermal(Heating/Copling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,salVroek type,Brain sire•etas). : Date Well Started g{,e D 4 D ft /0 ft -5E0`., • . 4.Date Well(s)Completed: 4I Ist! _ Well ID# 4(. 3 rJ/, /60 ft. •'toQ ft Giese , • 5a.Well Location: Phone#:336-q i•§-blil Z68 ft. 9 ft alOker, up 4frochurd . g py�, 2.6t� jj�� u,i t1 p P k e x . . -,1 S ft. , ,r z) ft 6 r.a r r 14f .[/fit ` p • ,. Facility/Owner Name . Facility lD#(if applicable) ' ft . ft I`'.i ' ',-t i/ R' �� / / & �,"�.�, jam . /Vr t. � r.5' /tux t� t�iliWl P e)47 MCA ft ft - Physical Address,City,and Zip .a�p_^a(A ft. ft SEP 1 Z 70Z4 �/Adamd ��V `Y !:I 'RF,1M"A`•R7{C�i,., :_T a. .e`•�i' .:.. . ., `" .i :•1- y:',_:-1 , •- ...® ,.. �Pd - . 7t,v:i,+i.t•:P,i: ;'.r.r.:F-';,1 i ' County Parcel Identification No.(PIN), f yr'..t%rc,v 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Certification: . • 36 `' 40i I " . N grl'' SO' ,2O'l W. 8fe?1/.2Y 6.Is(are)the well(s): Permanent or OTemporary signs ofC a ell Contractor Date 3, By signing this form,I hereby certi;fy that the well(s)was(were)constructed in accordance with 0) 7.Is this a repair to an existing well: ❑Yes or GNo • 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy f' If this is a repair,fill out laiown well construction it formation 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 ofthis form. 23.Site diagram or additional well details: 8.For GeoprobelDPT 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).You may also attach additional pages if necessary. drilled: i 24.SUBMITTAL INSTRUCTIONS • 9.Total well depth below land surface: 57)] (ft) Submit this GW-1 within 30 days of well completionper the following: . For multiple wells list all depths if different(example-3@200'and 2Q100)`• y p 10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR), If warn level is above casing,use bb (fit') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 11.Borehole diameter: ( ,)Bjf Off:f; (� s 02 24b.For Injection"Wells:Copy to DWR,Underground Injection Control gm) • Program,1636 MSC,Raleigh,NC 27699-1636 7_, e • 12.Well construction method: rad r min ey • • 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 I FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciniover 100,000 GPD: Copy to DWR,CCPCUA 13a.Yield(gpm) Method of test: eI' Permit Program,1611 MSC,Raleigh,NC 27699-1611 70% hth ® •Date Site Visited: 3-2'1 , 13b.Disinfection type: - Amount: d-i - Oz • --Site Visited By: A46 i , 9-3 Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 Price: , . .