HomeMy WebLinkAboutGW1--06151_Well Construction - GW1_20241014 •
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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: •
1.Well Contractor Information:
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rn'd_S HA f Erik wAlit.tiaoNEs > 3:.'t',:•.:.i.t'•: :a:..
WellContraetorName FROM TO DESCRIPTION
Ill(10 - /� 3fay fft. I
G loft • ft. it
NC Well Contractor CertificationNumber I:13'b w
UTER:eel.S1NG(ffi%mnlh<caded;welg:0R7y7NEIZ(iLap"lic`a"lile)`s;;a?.:i:.:: ..
Yadkin Well Company, Inc. FROM TO DIAMETER Ttsctnurss MA
Company Name pp $ ft in..
IL`IF1i'GASING.ORWDBING(keotbermarelosed3odd )'=" . ,.s.P_:3-'5:1• n!?.;
1 :: -
2.Well Construction Permit#: FROM TO . DIAMETER THICKNESS MATERIAL —
List all applicable well construction permits(i.e.Ufa County,State,Variance,etc.) „i, 1 ft. 610
ft Chi
hi in"
n (y1 n`^I [71�/' _
3.Well Use(check well use): ft I ft b ( in AEI r` [ l�V v
Water Supply Well: .7%SGRF$�:C.•:•::_..i, _= ;:,t3;i1?-, ';n;',1; >. -�.:c-:
FROM TO DIAMETER SLOT S+y THICKNESS
❑Agdcultural ❑MunicipaliPablic ft ft. in -3
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft in.
(1116-_❑Industrial/Commercial ❑Residential Water SupPlY(shared) :s <•_ ,.: .., - . _:�; , 1
• '•,:iZB.Git6U�li'�_..":`' ` :=�. :may SJ , . . ..:,:�...::`fs.»n�i�.'-:.,�..:;.C'_'...,e.,. � f�
❑Irrigation ❑Wells>100,000 GPD FROMpp TO u MATERIAL •1 t EMPLACEMENT METHOD&AMOUNT y'�+'
NonWaterSupply Well: 0 ft 02'_/ ft ,�, VA.1 tv. aLio.r 6r4v'L I
❑Monitoring DRecovery ft. ft / v `
Injection Well:
ft. ft.
❑Aquifer Recharge .❑Groundwater Remediation is19:SAND/GI9VEI2PACK(fpp1itilej''_-c„'--. ••7;i3 C;
r
DAquifer Storage and Recovery ❑Salimt Barrier
FROM MATERIAL EMPLA OD
DAquifer Test ❑Stormwater Drainage f
iel:
[(Experimental Technology ❑Subsidence Control ft.
❑Geothermal(Closed Loop) OTracer l 20:DRl=1:1NGTOG(sitta`cb'additIihariliiitiiiriecnsary) ":.._ ,:E`er';IT!,,S':.
• LI Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(eaSer,hardness,sail/rack type,grain size,ate.)
Date Well Started Z 0 S'o ft So c i
4.Date Well(s)Completed: /.�.#o7/WelllD#A4Q •"' I� I� i 0 ft YO ft �r►4 voc — Gra
5a Well Location: P,thone#: "7t�11-_,ii_°�v'ciS ) L(0ft. 160 ft oh y cr y
Li
Oft.
i p.cw��k - 160 ft' 2 trio' days r et, 2 .
.iJ P�"�1
Faciliitf/OOwnerName Facility D#(if applicable) 24 0 ft 80 9 I.ft ( i41-t,
wd.„ 04,.�/ si„0,lita,IVc.dg&o-i ft. ft .- - ��
Physical Address,City,and Zip ft ft. I C-,,''4... ' a i""! .` •
_. ..- -_. _.. _._ _. _. :•'2L�'B11 � - r,- ... .,v '-, `L7-= .•.d`D,•/r.raL•
Wni'-cia G.a.„. OL I i 4 2024.:
County ParcelldentificationNo.(PIN)
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees: .
,. •. _1
(ifwell field,one lat!long is sufficient) 22.Certification: �,.•,��v-
3( i o o N I i s 7 7� . W 2 _,2 •.( •(p
6.Is(are)the well(s):.�'ermanent or OTemporary
Signature of Certified well Contractor Date
By signing this form,'hereby cerh fy that the wells)was(were)constructed in accordance with i
7.Is this a repair to an existing well: ❑Yes or No ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 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).You may also attach additional pages if necessary.•
drilled: I 24.SUBMITTAL INSTRUCTIONS • ..
So 9:Total well depth below land surface: (R')• Submit this GW-1 within.30 days of well completion per tfi n/ef iflowing:
For multiple wells list all depths if different(example-3Q200'and 2QI00')
10.Static water level below top of casing: /0 U ) 24a. For All Wells: Original focal to Division of Water'Resources (DWR),
(ft, Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" •
11.Borehole diameter: C (in,)Bit Off: -Si i 7 7 24b.For Injection Wells:Copy to'DWR,Underground Injection Control(IQC)
Program, MSC,Raleigh,NC 27699-1636
12.Well construction method: A t' 12 4017 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) I/ county environmental health department of the county where installed
raj
FOR WATER SUPPLY ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
t Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Z Method of test: /Ay 411 i,/ 1 4'
70% hth oz Date Site Visited: 7=®l y i ,�
'
13b.Disinfection type: Amount: Site Visited By: '
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 6-6-2018
Price: m _