GW1-2021-05483_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
Well Contractor Name FROM TO DESCRIPTION
2135-A
ft. ft.
NC Well Contractor Certification Number
A&F Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 120' ft. in.
Company Name
2.Well Construction Permit#: FROM
SW21-0168 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.
IM141 ME
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS ZAMOUNT
Agricultural Municipal/Public ft. ft. in.
i
Geothermal(Heating/Cooling Supply) xResidential Water Supply(single) ft. ft. in.:[
Industrial/Commercial Residential Water Supply(shared)
h71 atlOn FROM TO MATERIAL EMPLACEMENT METH
Non-Water Supply Well: 0 ft. P0' ft* sandmix poured
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater 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
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) (color,hardness soiurock e, rain size,etc.)
ft. ft.
4.Date Well(s)Completed:June 24,2021 Well ID#
5a.Well Location:
Burgess Rockie
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Sourwood Lane
Physical Address,City,and Zip
Rutherford 327038 ( u
County Parcel Identification No.(PIN) '�ia�Il�i3ltOn pRaijon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 6/25/2021
6.Is(are)the well(s) X Permanent or Temporary Signature of Certi Well Contractor Date
By signing this form,I 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 ISA 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 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 J GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:—(1) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345' (ft.)
p 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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 1/4 (in.) 24b.For Injection 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) 5gpm Method of test: Airblow 24c.For Water Suuoly&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: asoz completion of well construction to`the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016