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HomeMy WebLinkAbout2505 Hwy 601S (2) WELL CONSTRUCTION RECORD for'Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: B�J 14.WATER ZONES rf) y'n I•�'' i"'C, E N i'..- FROM TO DESCRIPTION Well Contractor Name 3� ft i ft _303 GA JUN 0 k 20% pis ft. Baa ft NC Well Contractor Certification Number IS.OUTER CASING(for multi_ed'vells OR LINER if a licable FROM TO DL9.hIETER TIIICKNUS 1,1ATERIAL Yadkin Weil Company, InCD HEALTH ft. in. Company Name 16.INNER CASING OR•TUBING eothermA closed-loop) FROM TO DLAfv[ETER TIIICIINESS MATERIAL 2.Well Construction Permit#: /1/+/P F } ft. 7�I ft. I✓'� in. 3. .'ZO INC List all applicable well construction permits(i.e.C unly,State,Parlance,etc.) ft I & 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DMAI TER SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑MunicipaWtiblic ft. ft in. ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) t ft. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATEItL•1L EhIPLACEMENTMETROD&AMOUNT iaation z,1 F" ft. ft �'^ ,}� � f 6rrwl CL "Non-Water Supply Well: !� ❑Monitoring ❑Recovery ft. ft ,,, i f7 ,� -fJrt1 v/iNe Injection Well: ft ft ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable) ❑Aquifer Storage and Recovery Salinity Barrier FROM To h[ATERLAL TMPLSCE�IENT 11fETHOD ❑ ft t ❑Aquifer Test ❑Stormwater Drainage ft. ❑Experimental Technology ❑Subsidence Control 2 .DRILLING LOG attach additional sheets ifnecessary) ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,saillrocktype,e7•ain size etc.) 11 Geothermal eating/Cobling Return) ❑Other(explain under#21 Remarks) ft I " ft c l 4r— ft. eft. U 4.Date Well(s)Completed: o� (9 Well ID#44 7/x p U Jw 01 1�-a16-'ry2.�-sots /.t(.� ft _ ° ,� ft ,r Pt, 5a.Well Location: Phone number Ilkti 336- /tgSS-a2g6 /It1kc. ft ft LL1rI, 1 EIlA°a t�u_ixi'_ Pd,i{` ft. ft. Facility/Owner Name Facility ID#(if applicable) // //qq Al') ' / / ft. ft /-Wle 66 1 A),,44 ✓l')t 4'r�;`�6t-< ft ft. Physical Address,City,dd Zip 21 RENL,RKS c ( e /JGl[l!2i 41 I'd /��fTJ .I `A A lla County Parcel Identification No.(PIN) t d 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification (ifwell field,one lat/long is sufficient) q� 3S 0 J-0.,i F 7 N 0 S O 32, //-0 W Signature of Certified Well Contractor Date 6.Is(are)the well(s):`f4Perinanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance ,will;15ANCAC 02C.0100 or 15A2VCAC 02C.0200 Well Consin+etion Standards and that a 7.Is this a repair to an existing well: ❑Yes or >No copy of this record has been provided to the well 014117er. If this is a repair fill out known well construction h formation and explain the nature of the repair to7der#21 remarks section or on the backoflhisform. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well 8.Number of-wells constructed: construction details. You may also attach additional pages ifnecessary. For multiple in or non-water supply wells ONLYi dih the same construction,you can submit oneforaL SUBMITTAL INSTUCTIONS 9.Total well depth'below land surface: — yd— (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For n7ultiple wells list all depths ifdierent(ecxnple-3(a 2W and 2 @10 0 construction to the following: 10.Static water level below top of casing: +© (ft.) Division of Water Quality,Information Processing Unit, Ifwaterlevel is above casing;use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: GS (in.) Bit Off < C /t 24b.For Iniection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of,weil 12.Well construction method: Rotary Air +f Alvc t construction to the following: (i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) d Method of test: Ct!r 24c.For Water SunDly&Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: Cups completion of well construction to the county health department of the county where constructed, )ef r Form GW-1 North Carolina Department of Environment and Natural Resources—Division ofWater Quality ,,� Revised Jan.2013 Date site Visited: 5-1- ILI BY: AA Builders Name: Owners Name: Address: Address: Phone Number: Phone: Cell :Number: _5�3 &L -- ,DiJ 9- IC2116 60/ fell, J 1 ' 7 1 r