GW1-2021-04463_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2135-A
i
NC Well Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC. FROM I TO DIAMETER THICKNESS I MATERIAL
Q, ft- 7g ft. in.
Company Name s
2.Well Construction Permit#: RELO-0512 FROM TO DIAMET 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. ft. in.
FM sm
Water Supply Well: FROM TO DIAMETER ; SLOT SIZE THICKNESS MATERIAL
Agricultural ®MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) xBResidential Water Supply(single)
IndustriaUCommercial Residential Water Supply(shared) wit am I veff"
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. sandmix ( poured
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer
Geothermal(Heating/Cooling Return) r30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: 7/23/2021 Well ID#
5a.Well Location:
Robert Watts ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. r
Whistle Stop Farm Rd
Physical Address,City,and Zip PrQC,eSg
Rutherford 1654281
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 �'� 7/25/2021
6.Is(are)the well(s)EIPermanent or Temporary Signature of Certified Well Contractor a
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 X®No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,ill out known well construction information and explain the nature of the copy of this 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:+oue
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft•) 24a. For All Wells: Submit this 'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing:40' (ft.) 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 Iniection 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) 15 9Pm Method of test: Air Blow 24c.For Water SuDDIv&Injection 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: 32oz 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 f Revised 2-22-2016