GW1-2022-09614_Well Construction - GW1_20221021

®YELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.%i'ell Contractor Information:
1-Christopher Greene -
FROM TO DESCRIPTION
'Fl;i i Contractor Name ,
ft. Ct. i
2135-A I
ft. ft.
\l l\oil Contractor Certification Number r -_ -
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
p ft. ft. in. ;
t-amha;n'Name - ;
Rimplow
2.Well Construction Permit#: r !� FROM TO DL4MET THICKNESS MATERIAL
c,ii applirubie well construction permits(i.e. UIC.Counq•.State. Variance.etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
j Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0A,uricultural 13 unicipal/Public ft. i ft. in.
i
1Gcothermal(Hcating,'Cooling Supply) SfResidential Water Supply(single) in. ;
nIndustrial Commercial Residential Water Supply(shared) r -.
hrication FROM TO I MATERIAL EMPLACEMENT METHOD&A1tOCNT i
Non-1'4'ater Supph•Well; ft ft. sandmix poured
�ianitorine13Recovery
iJection Well:
•.aquifer Recharge 13Groundwater Remediation _. .
aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
kquiter Test 13Stormwater Drainage ft. ft.
r'.'oerimental Technology Subsidence Control ft. ft.
Geoth rn al(Closed Loop) 13TracerI.:,
Geothennal(Heating/Cooling Return) Other(explain under#21 Remarks) FRoat TO DESCRIPTION(color,hardness,soiUrrxk n e•rain sire,etc.)
ft. ft. l
4.Date Well(s)Completed: -2 Well iD#
-a.NVell Location: ft. t[. •'R i
Chad�i Zfif�>e.P�l�L5.�+3ifLL ft. ft.
r'acility`Owncr Name Facility iD#(ifapplicable)Lm
ft. ft.
4� ft. ft. 11*_'113fl
Physical Address.City.Aand Zip ft, ft.
�4 A ��in.�lLi..L�►rti dim�� '': m Fw�,Y�,�y >�`'`"*"z' :;�''.r
Parcel Identification No.(PIN)
i
;h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
oil field,one lat'long is sufficient) 22.Certification:
W /J •2 - Z22-
b.ls(are)the well(s)IOPermanent or 13Temporary 'Signature ofCcrtified\yell Contractor Datc
Bur signing this fnrm, I hereby cenih,that the well(s)was(were)constructed in accordance
".is this a repair to an existing well: Dyes or JJNo with 15.4:\'CAC 02C.0100 or 15,4 NC4C 02C.0200 Well Construction Standards and that u
,;:his is a r•enaw.fill nut known well construction in and evplain the nature ofthe copy ufthis record has been prnvided to the well owner.
r:nt,irr i remarks section or on the hock n(this_fnrnt. 23.Site diagram or additional well details'
s.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.
� � SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
1„i irc hs list all depths ifdii erent(eramp{e-3(d,200'and 2@100') construction to the following:
t 0-.-Static watEr-Ityel below top of casing:------ (ft). Division of Water.Resources,.information Processing Unit,.
above casing,use-+
1617'.Mail Service Center,Raleigh,NC 27699-1617
!'.Borehole diameter: 6 1 A (in.) 24b. For Iniection Wells: In addition to sending the form to the address it 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.aueer.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
i'a.field("pm) '.Method of test: Air Blow 24c. For Water Supph•&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: Chorine Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of NVater Resources Revised 2-22-20 it)