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Home My WebLink AboutGW1--06884_Well Construction - GW1_20241118 0. GST.ELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: rh " 1.Well Contractor Information: I I 3 iJIY 1 i R. 4t.WATR7ONESi,'.Z! :e .';' • I-.r-: • - '';';:-. ..'...r.:.:::::.•,,. .. • , ,...gc., Well Contractor Name FROM TO ' DESCRIPTION p • t 0 f L '7'C'� ft. I vo 3- kil - - • • LC )gyt NC Well Contractor Certification Number '7 ft A f ^) S'15.`01-DZEis:YsASING7G`(fZmultireli eiiieI17:01CLINE12'v'(i li-lic"`i.14li;; :':;. -- W.. Yadkin Well Company, Inc. FROM TODIAMETER TRICEICZSS 1 MATERIAL P • ft it in. ' �r CompanyName r = 68) NEECGASING'OR�>QBINC-(R`totl e:fibll cla"sedloop)°•:c':t`5.::<.�.. . 2.Well Construction Permit#: �n`3 9as 7 FROM TO . DIAMETER THICKNESS MATERIAL • _ List all applicable well construction permits(i.e.UIC County,State,Variance,etc) +l ft 1(lift I t h in.--j 2 I PVC, 3.WellUse(checkwelluse): ft ft . in Water Supply WeIl: s:J 7:�5CRF Yi',•.�;::Y: ±'c "{>,: : '°;;�'�"i}:'«2".::;>.: :-, :_::....;`<':C=;w" FROM TO DIAMETER~, SLOT SIZE 7 THICKNESS iMATERIAL, •• ❑Agricultu al ❑�M�,/un�icipallPublic ft. ' ft 1 in. ❑Geothermal(Heating/Cooling Supply) p csidential Water Supply(single) ft ' ft in. Dlndustrial/Commercial OResidential Water Supply(shared) Nirocat, r =__ ❑Irrigation ❑Wells 100,000 GPD FR TO . MATERIAL EMPLACEMENT METHOD StAMOUNf Non-Water Supply Well: • ft. f) ,(t ft j�(�a1e5 36 t., 4y ❑Monitoring DRecovery ft. 0� ft `'� Injection Well: ' ft. ' ft DAquifer Recharge ❑Groundwater-Remediation DAquifer Storage and Recovery ❑Salinity Barrier i'•'R`�/G o ` C' ' '� s.""`• •`:2 .:,;"•-__.j`.~ „ .� MATERIAL EMPLACEMENTMETHOD DAquifer Test ❑StonnwaterDrainage ft ft . . ❑Experimental Technology . ❑Subsidence Control ft ft ❑Geothermal(Closed Loop) ❑Tracer 1 ZO:DRIEGCINC:7OG.(attacli iddltilia-sliee`teifiieaT3siiiii :' ..,.. ..'' t . ❑Geothermal(Heatig/Cooling Return) ❑Other(explain under#21 Remarks) FROMTO DESCRIPTION(color,fiardness,soil/rack type grain she,etc.) n . Date Well Started a Qv-I.6v."1, �`,� 4 ft 57 ft ) 1 4.Date Well(s)Completed: ,0^"1 Well ID#�A t.9L=zi2 sal ft )(aft- 1 a'ti rc9reo v 5a Well Location' • Phone#: S3E,,-m r'dq-�o®(ci ft. ft 51-'� `•�`'__ • . LS rn f d •ft ft. U. It,.>. ._ - L.. • Facility/ Name Facility ID#(if applicable)); ft. ft. E9 P7°t!,°� �I e'V Mfdtarl c�• , el ft. ft NOV " r UtY Physical Address;GSty,andZip ft. ft lr;3;,..,.., Jm., '1. :21?i _"r:_6:2, .::.I+, 6n-jam..jCi� .................................................... ��l ou Cnty' ;f' Parcel Identitication No.(PIN) ($'1 5b.Latitude and Iongitude in degreeshninutes/seconds or decimal degrees: (if well field,one fat/long is sufficient); 22.Certification: ii: . ZC 0( q rr N 9.'6 p fec, qc w 4 • 6.Is(are)the well(s): IIPermenent or ❑Temporary S;' a oS thfied Well Contractor Date . , By signing thisform,l hereby certi,fy that the well(s)was(were)constructed in accordance with 7.Is this a repair to ma existing well: DYes or 19No 1SANCAC 02C.0100 or ISA 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 lhis record has been provided to the well owner. repair wider#121 remark section or on the back of this fans. o_ c?' - .. 23.Site-diagram or additional well detalst 8:For Geoprobe/DPT or Closed-Loop Geothermal Wells having die 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.dwells (add See Over'in Remarks Box).You may also attach additional pages if necessary. drilled: f 24.SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: f 7%2% 3 at) Submit this GW-1 within 30 days'of well completion per the followings For multiple wells list all depths iifdi different(example- Q200'and 2(g100) 24a. For All Wells: Original form to Division of Water Resources (DWR), 10.Static water level below top of casing: '00 (ft) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" 11.Borehole diameter: (it (in,)13jt off:f: .5 e 61 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) Program,1636'MSC,Raleigh,NC'27699-1636 • 12.Well construction method: I 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 0 FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA 13a.Yield(gpm) Method of test: a Permit Program,1611 MSC,Raleigh,;NC 27699-1611 tb�5 (T` ha .1' /dale. 70% hth . Date Site ViSited: -�I 2- ��' l 'ii'15 13b.Disinfection type: Amount: li oZ Site Visited By: O:I�� 11 ��r's 1 >9 ,P a� ZSs„ 6 hafar/4-arkef . • Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018 • it • i