Loading...
HomeMy WebLinkAboutGW1--06151_Well Construction - GW1_20241014 • • WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: • 1.Well Contractor Information: r 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 _