GW1-2021-00443_Well Construction - GW1_20211206

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
NC Well Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC FROM To DIAMETER THICKNESS MATERIAL
0 fL 66' ft. in.
Company Name FROM TO DIAMETER HI
2.Well Construction Permit#: SW21-0145 ER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. 41f
L in.
3.Well Use(check well use): ft. . in,
Water Supply Well: FROMTDIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public
x in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
N, lrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20' ft' sandmix poured
Monitoring Recovery
Injection Well:
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/Coo[ing Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,
ft. ft.
4.Date Well(s)Completed:June 22,2021 Well ID# ft. ft.
5a.Well Location:
Carol Brittner Sullivan ft. fc. ' .
Facility/Owner Name Facility ID#(if applicable) ft. ft. DEC 6 2021
3793 Hollis Rd Ellenboro NC 28040
MR '1
Physical Address,City,and Zip ft. ft. 1
Rutherford 1629531 rot
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 6/25/2021
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)colutnrcted in accordance
7.Is this a repair to an existing well: ®Yes or xNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 I GW-I 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-different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing:40 Division of Water Resources,Information Processing Unit,
Ifwater 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
10gpm Air Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
13b.Disinfection type: Chlorine
the address(es) above, also submit one copy of this form within 30 days of
Amount: ssoz 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