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Home My WebLink AboutGW1--05543_Well Construction - GW1_20240913 i W2LL CONSTRUCTION RECORD (GW-1' For Internal Use Only: 1.Well Coontractor InfeC , I/ Gr%- P")bl /1J ti n:V i?dy' (Yr Rx:4'.wA `ZONES'� z; ,•�•...: .t',:-. •. . ,. .........••. . , - Weil ConhactorName FROM TO DESCRIPTION s d ft. S 01 ft5 iP..., NC Well Contractor Certification Number Yadkin Well Company, Inc. *'1.5 bT) :0.191NG f6i u7ti`-casartiiells1:0111sI EI2i(al licalil'ef -&-::'-•. •: FROM TO .DIAMETER THICKNESS MATERIAL • k 3 7G Si a,�, y 9— Act f9 - 4-- I ft. ft G �S .in. ��, vC �_a�a`� w16-INNER:CASR�IG'OR�U$IN(T(1fe''otSecmaT'c1o'sgd3oop�':z'«'T`+i: c Company Name 9' % 2.Well Construction Permit : 0`M} V -FROM TO . DIAMETER ; THICEFRSS MATERIAL 1- List all applicable well construction permits(.e.UIa Comity,State,Variance,etc) ft. ft. in. 3.Well Use(check well use): ft, ft in. t17::S l f.t::r e._ 1 y I.. ..r--: .. ._4:;:,.a:i<::..:.. ._:.:....::c..'F_,'r!t.-- (IN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS , MATERIAL ❑Agricultural ❑M cipal/Public ft ft. M. ❑Geothermal(Heating/Cooling Supply) i_9'Residential Water Supply(single) ft. ' ft . • in. • • ❑Industrial/Commercial ' ❑Residential Water Supply(shared) , -, ..,,., ;s"i(i rGR�UT; ,. F "yq<<' , .t,�ti:;n-_ .:c` ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMFLA.CEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 2 2 ft hefvfx f 10 6 iav G 111 nr ❑Monitoring ❑Recovery ft. ft ItL2 Injection Well: , ft ft , ❑Aquifer Recharge •❑Groundwater Remediation ll.9::SAD/CR'9VFTa7,AQ((If"app"-It',cATe)p::::...,_ :�i:::d» l'i '.='.::.a .: - :Aquifer Storage and Recovery ❑Salinity Barrier FROM TO • _ MATERIAL EMPZACEMENTMETHOD ❑Aquifer Test ❑Stormwater Drainage ft ft. ['Experimental Technology ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) ❑Tracer i.201-D (ttiict'additwn'a1"sheete .nec'eissaiy?.' - .,._..-.. 'R17�IIVC�'i:OG a ;;%1 eti ❑Geothermal(Beating/ga gqlljn} g Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sal/rock type t size etc.) Date Well Started U i-(YL—Z- t 0 ft' 2- 7 ft• Orr' 4.Date Well(s)Completed:g 'Y -1-4 Well ID#,4i P d C 6 TB ft. -/! ii ft °ire"' i L 5a.WellLocation: Phone#:q'V-/ - Lo it/-3/6 .1) S ft 29 S ft ,fa.A.e (-4- l9 o //i�@I/ ��D A/L�t l f� Z 6! ft. 30 � c ft. -�finc.t - P-(J C kit- P✓ej 4- T�✓Yim 1 G P Facilityl6wnerName ® FacilityID*(rfapplicable) '3 ‘ ft. 3 2 Zft' 4t`�r.T Q�.-': --,•"".--. •Physical Address,City,and Zip ft. ft. J F P 1 . ,.# 1/4 h I !•Z1t;ItE1lCA131CS:`.:',`c :''_�•?.V . Z-ViE:::' ., : r' � . County Parcel Identification No.(EN) ter•.- r n'a Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` --- (if well field,one lat/long is sufficient) 2 C tineation:• _jCsp z2Off'® N ErO,'-7,5 3 2-1 w at I'1 6.Is(are)thewell(s): Et rmanent or ❑Temporary i co C Well Contractor ,/�' Date gning th arm,I hereby certi,fy that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: :Wes or IV 4'i l NCAC 02C,O100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy sr If this is a repair,fill out known well constriction information and explain the nature of the ofthis record has been provided to the-tell owner. repair under 421 remarks 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 to provide additional well construction info construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Yonmay also attach additional pages if necessary. drilled: / 24.SUBMITTAL INSTRUCTIONS CD 9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3Q200'and 2@l opl g�w 10.Static water level below top of casing: 73 `'— (ft.) 24a. For All Wells:.Original form to Division of Water Resources (DWR), 4, ' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" 11.Borehole diameter: 6, (in.)Bit Off: a.9 4f Q 24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC) /� Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: Air Pam® 4-4 lr'N 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the (ix.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) rr ' Method of test: U a Permit Program, MSC,Raleigh,NC 27699-1611 70°/n hth Oz Date Site Visited: �'— - - , 13b.Disinfection type: Amount: Site Visited By: 3-tqI I I ! Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 1