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Home My WebLink AboutGW1--06961_Well Construction - GW1_20241119 _ i • . 1 WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: I .....< ..—- I 0.) 1.Well Contras Information: ! • 1 a (:,..4 Fa.W.M1V-ZONEStN-..ZY:i.*.;z-.....:3".: '.• • ',-'r;:'"r• .i. :•;.,-..,,.-....2 :.4 3 . / : • FROM TO -.• DESCRPTION Well Contractor Name ;3S47-eY 170f /ft •frd. IC 0iN NC Well Contractor CertificationNumber 11:5701:13:XRI&S)NO:(f6FriiiilliWied;:iielriPOMS:InElfAianiainn;7- . "Si Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS 1MATERIAL ft. ft. in. Company Name cti 2.Well Construction Permit#: 3 el C L 3 4; U.'6511INJER1GASING'.0R,TUBMQ-CgTOtre:EilliireldigT-1116- 4::_.,.!!;!i$:=4:;,• • FROM TO • DIAMETERM TRINESS MATERIAL X. List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) s+ ( ft 31 ' C,30111- i:1 P2 6,„/ in. 3.Well Use(check well use): ft. ft. , -1:7.%grakkVc....k.i.. • : •=lin --q,2_11.7.37.:rz:_,•-•:—.--.=, Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL DAgdcultural DMImicipallPublic ft. ft in. • OGeothennal(leating/Cooling Supply) Ilqesidential Water Supply(single) ft. ft. in. DIndustriallCommercial . °Residential Water Supply(shared) X1SMR:billk::i.'e?,;=.•`P-z•M;I::-.'fkL.W.W:T..`i:7Vi:-...i;i1:7-'"7:-..:;:i:',:•=.::-.:7:27.:'2:'7E.':;"::` Ellnigation ElWells>100,000 GTD FROM TO - MATERIAL EMPLACEMENT METHOD&AM9UNT Non-Water Supply Well: 0 ft )3 fft. 1?-f,di.iiit a.'pl DMonitoring DRecovery ' ft. ft. p 19A54-...::. . .- • Injection Well: . . - . ft. ft. 'DAquifer Recharge . OGroundwater Remediation . 11.19.f.SANIVW05.21111A1V-1(ilWilgnire)M1'2“--‘n..- -..-:-.1•, -.1:... ..'-..i:;42'.:-...'. 7.; • :Aquifer Storage and Recovery EiSalinityBather FROM TO MATERIAL EMPLACEMENT METHOD, ' •: • DAquifer Test DStonnwaterDrainage ft. ft . '.,. .4 I•. DExperimental Technology DSubsidence Control ft. ft. ' .•• .. . ,. ...,- ..,.. OGeothermal(Closed Loop) . DTracer ;,iao.!-DRILUNGLOG(itfirjaaditigiiiTilieetitifilebliiiifk) Ma,-,Zr )`.i': e x-01r type,g ,e DGeothermal(1-leating/dOoling Return) DOther(explain under#21 Remarks) FROM TO DBSCRIPTION(calor,hardness,soli/ rain size, tc) • Date Well Started J U.-i 04 ii u: 0 " .5- " ___S; .,•,°•1• i ,•.(_ ix 5 • , •. '4.Date Well(s)Cernpleted: I;ii,o-g 7..).0 Well ID#AA a • 31 g.• .5- ft- la ft. ,. " Ptione#: ft. as- ft. Sie r i Sa.Well Location: .2 _ • 41.of lek, Y4,kip?,1 A 0 . . 9r-4---r CIA..5,.-.Xn.e . 2)-- ft 7Pc)ft rh•evi .(6.,ic•A- , g Pacility/OwnerName • • Fcility lii#(if applicaWe) .3 70 ft. 12,3 ft /n.-fai e ••r:. ".1-11 f ).4 , )* 7 9 LA 3)44 , .,„ Fdre. -53teiur ftfi.6o.oA-.07argb0 I ft. Physical Address,Cityft. ft 4 ,-4 '-.„-.'k.,,4 ‘i !4,..-.L: - - .-.31 ,andZip! ' _ . \ it I I es,,...1. AAA.. t.,,•,•. .. 1:•21•Sairafail/tsZ:,..-.=:,:•.:VIr..t!,11.-4.1M;,0i!,•;i1qty\pr)l•:-(a.234.',.W.:.,:-.?:g:.%3,:f. ..,,,... ,_.... County -41 # , , Parcel IdentificatiOnNo.(PIN) 11": :::':,,',"-..:::::'7 -7'-'—..-.•;:-•J ',:ii:: 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well BeId,one lathing is sucient) • 22.Certification: Ca . . ., 3:t1 0 N 3 1 e (0 9,5" 4 I/ . w oyyti12 E ,,,. _i_ /0,R -3H .,,, . , , .„, .::•.: . . ,,-• . -.',., 6.Is(are)the well(s):A..erinanent or DTemporary . Signature of Certified Well Contractor Date . By signing this form,1.hereby certify that the well(s)was(were)constructed in accordance with :. . • 7:Is this a repair to an existing well: DYes or *No ISA NCAC 02C.0100 or 15A RUC 02C.0200 Well Construction Standards and that a copy ; '•'. If this is a repair,jill out known well construction information and explain the nature of the of this record has been provided to the well owner. I ::: ,:. ',repair under#21 remarks section or on the back of this form. • -1. - ' 23.Site diagram or additional well details: . ,;,.._ •. -S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the a You may use the back of this page to provide additional well construction info. • sme 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 .. 9:Totalivell depth below land surface: I CU , (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths Vdifferent(example-3@200 and 2@100) dyad C., ' 1 ..? 10.Static water level below top of casing: 9 vo% ,,3/IL, 24a. For All Wells: Original form to Division of Water Resources (DWR), ' '''' k"!) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" 11.Borehole diameter: 6 oroeit Off: ‘,(3 EV '?..-:.,',..-::: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC) Program,1636 MSC,Raleigh,NC27699-1636 12.Well construction method: Ai r ro 4 A 7 24c.For Water Supply and Open-Loop Geethermal Return Wells:'CripitO the ••-...... (i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed , • . 03 ..-- FOR WATER SUPPLY*WELLS ONLY: ' , 24d.For Water Wells producing over 100,000 GED: Copy to DWR,CCPCUA co 13a.Yield(gpm) Method of test: r/y at( o • Permit Program,1611 MSC,Raleigh,NC 27699-1611 /n,41_ Date Site Visited: 3/ s 70% hth Oz . .: . . ." . 13b.Disinfection type: Amount: i'l Z"' Site Visited By: '18! .; ''-'. . ''.: ;..!:,'...:!•": ' . . % or;ii,d a-Po' + ii-loc- i n.3% . Form GW-1 North Carolina Department of Environments!Quality-Division of Water Resources 1" ',:.- Revised 6-6-2018 .• •-'•'•- •"'- , . P r i r p-