GW1--06979_Well Construction - GW1_20241118

'f-TTWELL CONSTRUCTION RECORD(GW-1). For Internal Use Only:
1.Well Contractor Information: 0
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FROM TO .•' DESCRIPTION
Well Contractor Name •: /
1.144q- A-- .:91,ft. 30.0 it. SA6 if(.c4rttifft,ezi / 15 poi
ft. ...: ft I '
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NC Well Contactor Certification Number
1;1:VOITITIZCO.SASTNOViirlifillti,!Clis"idNiaIEDDRIOTEgkirrnialireVfiV.;,'2?..V:': ,-,;:.
Yadkin Well Company, Inc. FROM TO DIAMETER THICKNESS mArrerha.
ft. ft
.
Company Name
ilfg:INNERIOASINGrOR:;TUBDTKgerraligan-ariliad;liiiini
2.Well Construction Permit#: 47 g- 1345 - FROM TO • . DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.LUC,County,State,Yirrirowe,etc.) + I ft
lik. ft• Sg(71 in- 67,11 W6 -. • _
in.ft
3.Well Use(check well use):
, Z.1.1aTtI ft tifin;;:-•.:7:-",e,27.7.,z.".7.:2",iP'ZIT=i 0...:',,,.;,P.1......_-_,TY.:1-"--1.77,4.-,-77,:.:,,,:,1'.-
Water Supply Well: • ,
sa.7 '. TO / DIA7 _SLOT Sr • THICKNESS MATIAL
I:Agricultural • OlVlunicipal/Public. ft
-
0 Geotheurial(Heating/Cooling SuPply) j>if esidential Water Supply(Single) ft. ft in.
ClIndustrial/Commercial °Residential Water Supply(shared) ViSFaftilitrei,:FRV7,'. .-.ti!-X41'-',5.i*:AtilV,17-r-7,.'-'..-..' ",;:..'•,21,1311`,":..1..%7'r::::',.,..?7.1-t;.'.,ri,'-
.. _. . _ •.
I:Irrigation .OWells>100,000,GPD . . FROM TO MAT8L r EmeLADEMENT IvqTROD&AMOUNT
. . . .. .
Non-Water Supply Well: ft.
0 ft. 2,5 Y3 ilef baqie* // 191.5.c
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DMonitoring .:•:':.:. ' DRecevery •' .=, - ... ---•-• ft ft.
Injection Well: ,..
...,` , .. _,
,.. ..,., ft. . ft • .
bAquifer Recharge . •:: OGroundwater Remediation ' •
Iasi's'
DAquifer Storage and.Recovery • CISalinity Barder I ' '.,'•:• • . FROM To . MATERIAL/ EMP ,Ihia 'a METHOD - •
DAquifer Test - • : . OStoonwateiDraina:ge,,,-- ft ---, ft .
•...-, .;.:, ,, , _ '
ClExperimental Technology CISubsidence COntiOr', .,..,-- . - ft. 1
DGeothetmal(Closed Loop)- ' , OTracer S g•20:f03 -GIO G.(ittliaricaditiOnifiliatfiriiiatiiiier;i4MU.;1.1a'EN.I.:.Q.7SY.
TO IIESCRIVI9N(color,hardness.sairoek type,grain size,etc.)
OGeothe,mral(Heating/Ccioling Return) .DOther.(explaininier#21 Remarksj
Date Well Started 0 ''. •- , 4 • . .. . ..,...... 0 ft ;20 ft. ,.01 /. ,._ .......•
4.Date Well(s)Completed: .1;44 ' ... - 0 ''
0,- r,. it.-weilm# . 0-..(71/3 ,. ft „loft .3.0 .... vocK,... ,-
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Phone#: 81W.A(9.,4:1;:112:0( It f.0 _,.ft• Vii61 , bot ji
Sa.Well Location: .
. ft.
C A a r i Ls . /V 0 it Ls .. _ , .,:...2 .,-',-, ---..:.:. • , ___,_... ....,,i--:-., ----;•
Eacifify/OwnerNaine ' ' - Facility thit--0apiiiCailley.-'1.: ; , ft.
_,?_i - l'i.1 1 I ki,• • 70- itititzict 201 ft. ft.•
- "U1L5t • . ' - LI':;:'''..
Physical Addrel;City,itii4ip ft. ft
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County ' Parcel Idenfific4OnNci.(PIN) -. -, -• 5b.Latitude and igngitidein degrees/minutes/seconds or decimal degrees:
• (if well field,one lattlong is sufficient) - ' 22.Certification: - , . • .
. :• . . . . ._
• 36 / • /I • .J 17 6, . N .31.(7 .361,. /1 -.1. . . .. 'Qv' ,_. . .
'
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6.Is(are)the well(s):10erm Signature of Certified anent or OTemporary . Well Contra Date
• .
.13y signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with •
7.Is this a repair to an existing well: DYes or ‘o 11SA MAC 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 this record has been provided to the well owner.
repair under#2I remark section or on the bock of:ids:limn,.
.. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells haying the same You may use the back of this page to provide arliiitional well construction into
construction,only 1 Gy-1 is needed. Indicate TOTAL NUMBER of wells (add See Over'in Remarks Box)..You may also attach additional pages if necessary.
'..s,
drilled: 24.SDBMTITA.L INSTRUCTIONS
9.Total well depth below land surface: goe)..., (ft) .
Submit this GW-1 within 30 dayi of well completion per the followingi
For multiple wells list all depths if different(example-3(4)200'mzd 2g100)
10.Static water level below top of casing: 160 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use"÷".
11.Borehole diameter: (0+ (im)Bit Off: al I if k 24b.For Injection-Wells:Copy To DWR,Undergound Injection Control(IEIC)
Program,1636 MSC,Raleigh,Np 27699-1636 .
12.Well construction method: 4' r rah+12 f y 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the 0
(ie.auger,rotary,cable,direct push,etc.) county environmental health depatbnent of the county where installed' ..........
TO
. FOR WATER SUPPLY WELLS ONLY: • 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA cri
Permit Program,1611 MSC,Raleigh,NC 27699-1611 ...r.-.‹
13a.Yield(gpm) ,__••3 Method of test:_Pi x A,I' rt).
Date Site Visited: 3- Ir -2 q .
70% hth r oz ._1 ,..
13b.Disinfection type: Amount: Site Visited By:
1
re- CON i .. ._. •
Form GW-1 North Carolina Department of Environm I-tal Quality-Division of Water Resources: -----7-' Revised 6-6-2018
Price:
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