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Home My WebLink AboutGW1--06154_Well Construction - GW1_20241014 • •- �yVJE I,CONSTRUCTION RECORD(GW--11 For Internal Use Only: • 1.Well Contractor Information:: 0 C ��7 / ki t��- /P�d - sjA.WA `ZONES•`•. ��:.•.r:•. •..^,'..:., - i..+.:'::. , . . - ��`° FROM TO .• DESCRIPTION Well ContractorN/atme • i o‘d- ft zA)ft b .1_,,re,� fL A"a ft Ill 'r NC Well Contractor Certification Number •16707JT1;:'G1 iaiili S1NO lti` `OIZxvri i i$`s•`ra81ef.•i;,-I. Yadkin Well Company, Inc. FROM TO DXAMET THICK-MSS1 MATER/Ar t j ft 5 ( ft In. Al V. Company Name I�� ?)16'�ZN�;C9SILIG2OIi3'UBII�'G:�eotSeimal'cldtie3=locP�:.,_.=:,�4.,::>.:`,;.•.. 2.Well Construction Permit#: ` /1\1FROM TO • DIAMETER THICKNESS MATERIAL — List all applicable well construction permits(i.e.UIC,Cowtfy,State,Variance.etc) ft. ft I in- 3.Well Use(check well use): ft ft in. Water Supply Well: • -s:i7:CirF Tie:i '" : .!'_f1:V;11..:..-1,;:lz- ' ;t:, a C'_.�:; a,':_: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public ft ft. in. ❑Geothermal(Heating/Cooling Supply) ❑Re;idential Water Supply(single) �" ft ft in. ❑Industrial/Commercial esidential Water Supply(shared) . - _ - • t18`;G'1t011��"M`i"_`',':iXr�� ;+:.�L's' ': :' �'S%�.�`.4a.'.•.a..,'� _:1-„ ❑ltrigation ❑Wells>100,000 GPD FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft t t ft b ,`#ice p®L' cA t'p S DMonitoring DRecovery ft. ft Injection Well: ft. ft ❑Aquifer Recharge ❑Groundwater Remediation ❑A uiferStora Storage ❑Bolin Ill9.rs�/GR&V ''A (if h 13re)M._. :,_'-;.?v2="s/.:—.1ct: ::;,:,^: q g ityBarrier FROM TO MATERIAL EMPLACEMENT METHOD 3- ❑AquiferTest ❑StormwaterDrainage ft. ft ❑Experimental Technology ❑Subsidence Control ft. ft. ❑Geothermal(Closed Loop) OTracer t 20:DRIl tIlleI:OG.(attachtaddifionaI•slieetiid,necliiiiiTy) .`=Kf;',,,:.”:. ❑Geothermal(Heatin ooli o-Re;1.. ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sol/reek type grain slur etc.) Date Well Started"f---I ga'4. /� ` 0: 10 ft U(T 4- 4.Date Well(s)Completed:i •3�-2i14 Well ID#PM l y�. a/ i fL ', ii ft ' e ''QI Phone#: '� 5a.Well Location: ((, fi ' it. //111) it )r`vrl. Q 4- . ,i 6 e�4,P V�ad� CI ,& ft. ft. t.. 61/ Facility/OwnerName Facl ity ID#(if applicable ell ft ft. ,^t . 150k r a 'ig 63s -_ ft ft our /� Physical Address,City,and Zip s ft ft 1!'r` -�✓ U[ ` A b'!1"5 :Z13li1?.11ZABYtC ,... :i;-" .- i i:: 11 - ti .,. +v.. „x•.,. :1:Z7 County Parcel ldentrfica±aon No.(PIN) 't- r®'e- Ke'J I . f' `, i. ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one Iat/long is sufficient) - 22. • catio • VCIAZ553E50 N 4211.1O?E0?0 W ,�1 4 4 ."0-.2m, 6.Is(are)the well(s): ❑Permanent or DTemporary Si a of edWeilContractar Date By o ' is form,Thereby certify that the we11(s)w% (we're)constructed in accordance with 7.Is this a repair to an existing well: DYes or i!JNo . • 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy , If this is a repair,fell out blown well construction information and esplain 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-Loo Geothermal Wells havin the same You may use the back of this page to provide additional well construction info constmction,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: 24..5uBMr TALINSTRUCTIONS 9.Total well depth below land surface: 1 y ® (ft) • Submit this GW 1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3Q2110'and 2(41100') ;Kew. . 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: •�`'-ti (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use'+' - S 3 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) 11.Borehole diameter: (in.)$i. . Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction method: (&t�I.' I 24c.For Water SnppIy and Open-Lop Geothermal Return Wells:Copy to the (i.e.auger,rotary,cable,direct push,etc.) - county environmental health department of the county where installed 0 FOR WATER SUPPLY'WELLS ONLY: w 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA Permit Program,1611 MSC,Raleigh,NC 27699-1611 13a.Yield(• gpm) d Method of test: C o /� Date Site Visited: . - 13b.Disinfection type: 70/o hth Amount: -( 1 OZ Site Visited By: 1 Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 Price: