GW1-2021-04461_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
4.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name
ft. rt.
2135-A
R. e.
NC Well Contractor Certification Number y -,...
A&F WELL DRILLING, AND PUMP SERVICE INC. FROM TO DIAMETER i THICKNESS MATERIAL
0' f 37 t. ft. I in.
Company Name
2.Well Construction Permit#:W21-0337 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: FROO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) $ ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft' sandmix poured
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer
FROM TO DESCRIPTION color,hardness soil/rock type, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 7/23/2021 Well ID#
ft. ft.
5a.Well Location:
Breeden, Charles Robert
Facility/Owner Name Facility ID#(if applicable) ft. ft. y 02�
283 Coffee Rd Forest City NC ft. ft. _ it
Physical Address,City,and Zip ft. ft. �lifOICY',3t10I1 sorf,OI1
Rutherford 1652680 ,,. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W OLW7 wo -' 7/25/2021
6.Is(are)the well(s) x Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of th&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-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'oNe
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305' (ft.
p ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 30, Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 A (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 gpm Method of test: Air Blow 24c.For Water Suaniv&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: Chlorine Amount: 36oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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