GW1-2022-00321_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I I
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name f
ft. ft.
2135-A
NC Well Contractor Certification Number
.15:.OLITER�CASII�TG(ftirmulu-easedl�elk,OR'.LTNERf a`�hiti6le'
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
ft. I n ft. M to
Company Name ��""�� �'1I / ^'16:?I1V1\'ER_CASING OR:TUBINNQ AW&;tnaf ctbs`ed=Coo . s
2.Well Construction Permit#: 100 4(0 FROM TO DIAMETER. THICKNESS I MATERIAL
List all applicable cell construction permits(i.e.UIC,Coun),,State, Variance,etc.) ft.
3.Well Use(check well use): ft. ft. in,
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
NAgricultural [3MunicipaUPubiic ft. ft. in,
Geothermal(Heating/Cooling Supply) ORcsidcntial Water Supply(single) ft. ft. in.'
Industrial/Commercial Residential Water Supply(shared) ,18:GR(>Ul
Irrigation FROM TO v MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. P0' ft. sandmix poured
Monitoring Recovery
Injection Well:
ft. ft
Aquifer Recharge nGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothennal(Closed Loop) EiTracer ",Zt►..=nRiI LtNG.k,Q,G;(attacladdipoBShsheets°if n`ecessart% P,
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
4.Date Well(s)Completed:12'(Q-M Well ID#
5a.Well Location:r,r fttt, ft. ;S m":'�"" S�. f Vr-"
urclQU ft t Idtr 3mMef . ft. '6"°, a V A_Lw
Facility/Owner K ame Facility IDn(if applicable) DEr t
1 wnn
Physid'Ai
,tAddress,City,and Zip ft. ft.
I�li'f Y1Pr�orc] I 0 5 (P OO!
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 222..Certification:
6.Is(are)the well(s)MPermanent or Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or EINo 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 421 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-1 is needed. Indicate TOTAL IN'UMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'k" loll&') 1' SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 24 5 1 (ft-) 24a, For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �O, (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Iniection 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 Sunnly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine
13b.Disinfection type: Amount: 3 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