GW1-2022-09963_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Christopher Greene
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I
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2135-A
NC Well Contractor Certification Number
a15.�0U1'ER`CASIAIG;;Eor riiti-cased?weils'Qlt'I:11Y1�Iti`ifin ca61e': .-.�"� ,:;;'>
A&F WELL DRILLING, AND PUMP SERVICE INC FROM To DIAMETER THICKNESS MATERIAL
0 V ft 1
30 fL [4 in.
Company Name T S1NG;01t3T3BINGt e°tEherfti»!(elosed ioo b 2.Well Construction Permit#: FROM TO DIAMETERi THICKNESS I MATERIAL
ft.
List all applicableacell,conshzteNon permits Q % ft.e.UIC,Coun State, variance,etc.). _ in. _
3.Well Use(check well use): ft. ft. in,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) Q18 R Bi
Irr,igation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. Ct. sandmix poured
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
,19.;SANDfGR6F, 11.PACK';d "lie"'
Aquifer Storage and Recovery E3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) EiTracer stO DRATANG°XUG(atiacti`additional"sheetsif
Geothenmal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness soiBrock a rain size,etc.)
qq������ E� /� ft. ft.
4.Date Well(s)Completed:10,1 -olIi01� well II3# 2�lJ ft. ft.
5a.Well Location: ft. ft.
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Facility/OvIner
,,N�aamee Facility IDA(ifapplicable) ft. ft• NOV V 4 2022
Cw l /1 ds ,R iye
Phvs'cal Address,City,and Zip ft. ft. i ~`rJ-Iatj30G
P95.111)TV
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon g is sufficient) 22Certification:
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6.Is(are)the well(s) MPermanent or Temporary Signature of Certified 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: nYes or EJNo 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 arplain 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.S1 te 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'° SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: L405 (ft-) 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 @100D construction to the following:
--`-i�5taric water ievei-below-op o 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.anger,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) 1BQ0MMethod of test: Air Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
ja r� the address(es) above, also submit,'one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: `7 completion of well construction to Ithe county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016