GW1--05540_Well Construction - GW1_20240913

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."--;WELL CONSTRUCTION RECORD(GVV--11 For internal Use Only:
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.Well Contractor Information: i • 0
`Ai i trCeil.. ,i,g. C)6('/'e:' .::• .t KiliWATEVZONF.550=:1-;r...,-, ..f•-,I..:1• _.;-•:.1r- ::„. .,.,.-;,..,.., ... ;,.,
FROM TO . ' DESCRIPTION
p'a Well C'entracaorNaroe ' ' - ' ,'''' :::. —0
cif a ft. (00 ft. ? I 1
I 1 Nd Weli Contractor dertifieation Ninth=
Z.13'.''01333T1CCA.-S11,70.(feiniiiiltirelsIiiiielVI:0111.130.0iW."liairiM':',:.:.. : .s --
Yadkin'Well Company,inc. ' .; j- • :, FROM TO DIAMETER I THICKNESS 1 MA'rERIAL
ft. ft. J .
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,CotapanyNatae __. - '
et ...4...: e ,.. nDINKRIG&SING:ORaU.LIDT.Gf(rerdther7datrad'iga;IticliP. ...
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Z.Wc11Construction Permit#: ,---„,-, 11.1-.4.. 8 7 FROM TO • DIAMETER THICKNESS MATERIAL
gsfallapplicablewellcansiructionpermiti(14,Ella7Cata*,Strste,Variance,eta) • pi ft. 14 ft ‘.(43.5,—in. f ma i p vc
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3.Well Use(cheeltwell.use): , . ft ft in.
. . , -EIN..g..CIAM*2!;VX.X.,-.-.F.t,11:t47.rk,if';:t.=.:27.1:1VILLL:a0&,,i'illiCZ'n't;t1';,:,:::.:.`..3:1-CM--.Cni,-er,V-.,
Water Supply Will: -
: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -•r
134gdelltiagal — ,OMunicipal/Public ft. ft. in.
iCIGeothensialVieating/Cooling Supply) 1.[IReSidentlafWater Supply(single) ft ft. in.
Cantinstiial/Connercia) ' . IDResidatial Water Supply(shared) i.tImrotivin.:IL•asfl.,t;--,•; .irt;,cM":7:1‘ttaf.11!‘":;Z-'.1,e,r.-4*:12D,;1747.1T....17,7.:17:0-SZ.;1,0;-
ElirrigitiOn ' 'ClWells->106,000 GI'D FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
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Non:Water'Supply Well: , 0 ft. ft. genie,'le a;e.S pdorel
['Monitoring , " :1:Recovery' • ft. ft. /0 A5i 5
Injeetloti Wen: - ' - — cr;`,... l'—,i''''ir-7.:I;\[r.." ft. ft •
DAspd:fer Recharge ItlGroundarideikieinectAtitm' '' '"" '
' 11191Ts'ANbratiatleMlifitirMiretwo'f.,-;.,:k-,.-zgr,132.-..-,2,
ElAtpliferStOrage and,Recovery ;EISalinity BanterE p 1 S 2024 FROM TO MATERIAL EMPLACEMFNT METHOD ' •
,ClAqtAfer Test . IbStorinwaterVramage ft. ft
['Experimental Teehnoiegy • I1lSubsidence,COnhtd,-,1 71 rc...c••4r74:7-'02 014-‘i ft. ft
. ,4....,0
13Cseot!tiwrnal(Closed Loop) ,PTracpr D'A''‘'•-'i"/ Ll.2,01DRittiNGIOG(iittlirJ''filaditiiiitirslieltliaieeeiTary-P5Aars=7.1a';'1,752:4,71zig. ' ' '
FROM ft. TO ft. DESCRIPTION(color,hardness,soS/rock type,grain size,ate.)
] OGeothtUfnal(Heating/CtiolinaRetint) ClOther(explain under#21 Reinarlcs)
DOte-Well Staffed 17---4.-agf2- - - - AA,,:— i ry f: , ,r,.
4.Bate Well(s)Completed: -IS- '4 Well ID#rtrr IA.-.04!"I 19 7 36 it' se Fri.' 6670/A
5a.Well Location: • ' :Pi'fone#:_ 10.•.:66'1.-142.4 9( ft. Sl- ft. -I-,ic7'L 569k V.-
7
ft*
1
G .Pioch tiat-' ''
Ee•vt , . .60, I. , , uo3 e"Fed .D c 7 5 tr-21;1--e ---: ,
- piiitY/C).wan r Name , - - . : Fgoilitylitit(if applicable) ft ft
14w 7 111 -$.1 Vi i A'5,1sil e67-- p ft. ft. . .., .. .
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- - ft. ft.
l'hyslpolAddepp.City,and-Zip
W 4- ' ' '
Ct Otuo)c4 ' ' . vo.-..t-it/Armitsze:7-ssezi.,::k1,1!aiz.x.K.,Y.,::;T::.::•..i.A.-,.y, - . .p....---..e../gsz.7;.....
County `-"' Parcel Identification No.(PRN1) y dr a Froc 1;0 i lop 0 - 700 g.: ,`•:;.i 01 ' •-',
At,'• : ' ;=-©
8b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I i 1/D 0 60 t
(if well field,one 1st/long is sufficient) 22.Certification: 441-0.1 70 0 -
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• - . 34 —2 2, SsT:o N 1-1 e 11 ico 2 0\k, w (Ylit— ECApe- .
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Signature of Certified Well Contractor 7Dat:I S..-.1 II .*'-7--
6.Is(are)the well(s): Pirermanent .or ,IDTemporary
By signing this form,I hereby ceritt that the well(s)was(were)constructedin accordance with ',1,"
7.Is this a repair to ant existing well: ,111Yes or No - ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy r
..urthig Lea repair,fill out Imam;well constructionipformation and explain the nature of the of this record has been provided to the well owner.
repair Under#21 reetarksiection or on the back oft/tic form.
is
,. 23.Site diagram or additional well detail :
.8.For Geoprobe/DPT or Closed-Loop'Gunther-Mal Wells having the same You may use the back of this page to provide additional well construction info
,coustruction,lonly 1 GW-1 is neerleil Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
. a' 24.SUBMITTAL INSTRUCTIONS
, 9,Totsdwell depth below land surface: = I ...?
0 1/4 (ft.)
Submit this GW-1 within 30 days of well completion per the follovvingi
For nada)*we lIslist all depths p'"different(example;3®200'and 2@.100) ,
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below top of eating: ___ ' :es 24a. For All Wells: Original loon'. to Division of Water Resources (DWR),
10.Static water level
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If wafer level is above casing,use"t" ',' 1, , -
,-! ro Off: Li iil 24b.For Injection Wells:Copy to DWIt.,Underground Injection Control(IUC),2
11.Borehole diameter: ., ‘ ' ',pm)uo ft 5 , 9 „
Program,1636 MSC,Raleigh,Ng 27699-1636 -,,,,
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12.Well eonstruction Method: ot;e,' -rtr t-ary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le-gager,rotary-,cable,directpush,etc.) ' county environmental health department;of the county where installed
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FoATER supisy'wEus ONLY: , . ,
P24ernaid.ii:toprroWgrana,ater 1611Wells mpsrcod,Ralucinegigoh,vNer1 20 70 6,090904G6Pi Di : Copy to DWR,CCPCUA I-
.:. a l'/ --PV.----
,...Tidatgp.) .-tk ' Method of test's
-- - A Date Site Visited: I
70% hth r- CO
. 13b.Dithifeetion.type: • Amount:t ". 0 OZ Site Visited By:
Form d..1-1 North Carolina Department offinvirolunental Quality-Division of Water Resources Revised 6-6-2018
Price: