GW1-2022-09585_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name
2135-A
NC Well Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. .in.
Company Name
10096910001-
2.Well Construction P¢Cllllt#' M3a DIAMETERTHICKNESSFROM TO . THICKNESS MATERIAL
List all applicable well construction permits(i.e. C,Cou ty.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS /MATERIAL
Agricultural unicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared)
Ir ri ation FROM TO/ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. X ft. sandmix poured
Monitoring ORccovery
Injection Well:
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer-Test [3Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 13Tracer ,,...:
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiurock a rein size etc.)
ft. ft.
4.Date Well(s)Completedse&Vw Well ID# P-Pat
5a.Well Location: �\ ft. ft. R. ,
J ft. ft.
Facili ;[Owner Name 1� Facility ID#(if applicable) ft. ft.
ft. ft. trAoron&tton Prmaoe ft UM
14
Physical Address,City,and ip
ft. ft.
U2409S2 0
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.Is(are)the well(s)RiPermanent or Temporary Si nature o crtificd Well Contractor Date
Btu signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.1s this a repair to an existing well: 13Yes or SdNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair,fill out known well construction information and explain the nature of the cop),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:
R.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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:1011
/' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: %%rJl lam/ (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@000') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
0water 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) Method of test: Air Blow 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
36
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chl ne Amount: 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