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Home My WebLink AboutGW1--05560_Well Construction - GW1_20240913 i WELL CONSTRUCTION RECORD(GVE7-11 For Internal Use Only: I : ,� 1.Well Contractor Information: I ' , or n,t(kC;) 6 ‘‘,...e. Rik WATER'ZONES^?t= 0 :`: FROM TO DES CRIPTION Well Contractor Name I'l r�tt '3(,i' ft I 1 3S 4i-� ` ft. ; ft . I NC Well Contractor Certification Number ,.... ..,.:,., :1.5."OIISER:G�TNG`(foimulfi:cased��velU�`:OIt�VEIt(ifap`lic'"ba'lef,.,.�:. _ ... Yadkin Well Company, Inc. FROM TO DIAMETER ; TmcRNESS MATERIAL.• . ft ft .in. CA Company Name 7 / ! 7� alga NERC-ASING012e1:uliING: eotliecmal"close3laop�._,: LR,hi,,,:... • ra 2.Well Construction4j /`�� (� �i Permit#: FROM TO . DIAMETER , TRICt1YFss MATERIAL �° List all applicable well construction permits(t e.UIC,Cowity,State,Variance,etc.) + J f ft �1'r1 S' m- SDP a 1 ()1 i! �_ 3.Well Use(check well use): ! ft. ft d in ('� ((!Y L 3 r Water Supply Well: r17 S'.Cl :' . . .. :"y a ::'�.'-�:,.._:_-�1 5n" ', FROM TO DIAMETER4 SLOT CT7F TRICKNESS MATERIAL _ ❑Agricultural ❑Municipal/Public ft ft, in. ❑Geothermal(Heating/Cooling Supply) 6esidential Water Supply(single) ft ft in. - ❑Indushial/Commercial ❑Rt sidential Water Supply(shared) ^s.,, , - ❑Irrigation ❑Wells>100,000 GPD FROM• =.' TO MATERIAL EMPLACEMENTMETHOD&AMOUNT Non-Water Supply Well: 0 tr' V-t ft j. i61+I L C L, I p f p4( t r el OMonitoring . ❑Recovery ft. ft 1 S. 6 Ays Injection Well: ft. ft J ❑Aquifer Recharge ❑Groundwater Remediation i . ❑Aquifer Storage and Recovery ❑SalillityBaizier -'•19:.SANO GTtAPETfFA:cle Eipplicab"Iej ._ �.i.- ;,"i.. �. PROM TO MATERIAL EMPLACEMENT METHOD ❑Aquifer Test DStonnwater Drainage ft. ft ❑Experimental Technology ❑Subsidence Control ft ft. ❑Geothermal(Closed Loop) OTracer i 20fDRIEfING-I:OG(attlieli-a'dditinnil i eetr ifiiec"e-ss`ty-) u=Earl T ;':; 'C:_ FROM TO DESCRIPTION(color,hardness,soil/rack type,grain she,etc.) ❑Geothermal(Heating/COolingReturn) ❑Other(explain under#21 Remarks) Date Well Started ri-g8 0 ft it ft p o 4.Date Well(s)Completed: 7`.' 14 We11ID#.TI/�r Q- L 3 0 La ft 10 ft Sc F-I- bIC Ill sJlw c lfc 5a.Well Location: 'Phone#:761 7 77 '--63u: go ft. 1? ft ili r�,1{ rA �f,�e 4ii.�$ '� 'Tim d/ Pr)C e, - 1Jcc Killion j 0 6 /ql f�� 1"® y r�j�J �/titl/y., C/te,-..if e M r', Facility/Owner Name ,: Facility applicable) [,-- ft ?G?- %.ir 5 rosy 5 re-n, l'- Physical Address,City,and Zip - -. • uc' ft. ft �: ;•----,,r a, `r-..-- "v , 1'. &1 �,1 . . t21'GR�.,hA'.S•TRYCCrw'. ;'`>: `;�',- ::v_-i \+e."r.;li�.-..,."/.1 j..f. .-,___•... County � Parcel Idr tificationNo.(PIN) SE iD 1 t; 2024- • 5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: . J. (if well field,.one let/long,is sufficient) • 22.Certification: Irk:,;r,l'�i r- ?'�-r.7";;•`',y tljf,:.l , 3 b m •i i 12 0!. N 3! ° *I '..r •( W Q`e.,.u'L.r(n , ri-33-2M 6.Is(are)the well(s): permanent or OTemporary Signature of Certified Well Contractor Date By signing this form].hereby certify that the well(s)was(were)constructed in accordance with ' ' 7.Is this a repair to an existing well: ❑Yes or K Io . ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy If this is a repair,fill out known Well construction information and explain the nature of the of this record has been provided to the well owner. • repair under 1/21 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 constmction 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. filled: I • 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: go. -(ft) For multiple wells list all depths ifdfferent(example-3t 200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following: 10.Static water level below top of casing: ia o Q\ (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR), a( If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 , W 11.Borehole diameter: 6 (in.)Bit Off: 6, 1 0 ( 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) (, Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: • G/T' co 71-ea/t 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.Ivor Water Wells producing oven 100,000 GPI): Copy to DWR,CCPCUA �,� Permit Program;;1611 MSC,Raleigh,,NC 27699-1611 13a.Yield(gpm) Method of test y` // ;� , 70% hth Date Site Visited: JQ 1,, 116 .- . • 13b.Disinfection type: Amount: 0Z Site Visited By: fs� 3/�4 " 6 , .. 1 , 4 t . . • �. 111T1 mini'GW-I North Carolina Department ofEnviroianental Quality-Divisionof Water Resources ' ;Revised6-6-2018 . -Price: , i D