GW1-2021-04653_Well Construction - GW1_20210514

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene a
e
Well Contractor Name y,9, FROM TO DESCRIPTION
ft. ft.
2135-A ft ft.
NC Well Contractor Certification Number
1 2�21
r�1 py.
• 1
A&F Well Drilling 1��Ej Bs;� t C( 1;�11 FROM TO DIAMETER THICKNESS MATERIAL
Company Name
e
2.Well CDnS1CUCtlOn Permit#' SW21-0136 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count)-.State, Variance,etc.) tt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) tt. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT/
Non-Water Supply Well: 0 ft. 20 ft. Sandmix Poured
Monitoring Recovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stonnwater Drainage
ft. ft.
Experimental Technology E3Subsidence Control
Geothermal(Closed Loop) 13Tracer _ ' _ ffowwwwwwa
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: May 5,2021 Well ID#
5a.Well Location:
Loyd Greene
Facility/Owner Name Facility ID#(if applicable)
Whitesides Rd Rutherfordton NC
Physical Address,City,and Zip
ft. ft.
Rutherford 1633099
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'
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certified Well Contractor Date
By signing this fornn,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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 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 welldetails:
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:' I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (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@100') construction to the following:
10.Static water level below top of casing: 40' 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 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) 40gpm Air Blow Method of test: 24c. For Water Supply&Infection 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.
Fomr GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016