GW1-2022-00324_Well Construction - GW1_20221222

11 L+LL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
I.Well Contractor Information: j
ri
Christopher Greene :I4 t3TE12ONES_ 4 _ ,_.Naine ,
FROM I TO DESCRIPTION
2 i 35-A !
tt. tt.
\.'R eil Cortrartor Certification Number _..
s�io.;OL?TER GASI1bfoGtueltl-cased✓:�ells��1�3�: h��a�-p t;:�:.. .
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER ' THICKNESS MATERIAL
1 Iv .^ ,f=16
'_.1't ell Construction Permit#: sa IJV��Q FROM /TO DIAMETER' THICKNESS MATERIAL
unpiiruhie it-ell construction permits(i.e.U1C.Counh•.State. Variance.etc;) ft. ft. in.
3.Well Use(check well use): ft. R, in.
Water Supply Well: -'I7.'SGItEE1�`
FR011 TO I DIAMETER SLOT SIZE THICKNESS MATERIAL. I
DAgricuiturai [3Municipal/Public ft. ft. in.'
:_,:'t icoihennal t Heating Cooling Supply) JoResidential Water Supply(single) ft. ft. in.
industrial Commercial []Residential Water Supply(shared)
rhTigatlon FROM TO MATERIAL EMPLACEMENIMETHOD&ANIOUNT '
Non-Water Supply Well: ft. CDO ft* sandmix poured
%lonitorinQ 13Rccovcry ft. ft. i
ia.iection Well: fr. fr.'Aquifer Recharge [3Groundwater Remediation
�,. 1g S7GIi:�k�)`.%P�iGI{:r� ._- ..3�s�•:<„r-,�,. ��r�".e�r._r:.�+�;:.:.:`r";•..
�f;Aquifcr Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EM1iPhACEMENT M1fETHOD
Aquifer Test 13Stormwater Drainage
D%snerimental Technology Subsidence Control
1(3;!othemral(Closed Loop) 13Tracer1?I211T.LAG`1sY)f'(atCstl addidousts7reetsaf""" c �x' ?�� ..:r
FROM TO DESCRIPTION'(color.hardness,soillrock e,grain!
Ci::,xhenrai(Heating/Cooling Return) Other(explain under#21 Remarks) ft ft
Datc Well(s)Completed:5- -x0v Well iD#
Sa.W;11 Location: ft. ft. a G-G
z«41nski Maid ft. -
.:::i;i:c ChPner dame Facility iD",(if applicable) ft. ft. ~ 2 HE
33$ S C � �� ft. tL lftii�i t : :l `'i:",'.ter. 7
Cj'i�;�},•..r/and Zip 77,
1 t8 M•( P 11 I�f/�`)TIJJ -A1: IMI(��.+N':.'u ��' _e,t'., ..��'.'.-'���.vd�.x.'�,Iw::X,��+".e�. 7?a..i
Parcel Identification No.(PIN)
Si,.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
crli field,one inrlom-,is sufficient) 22.Certification:
I'
6.ls(are)the well(s) Permanent or Temporary
sienature of Certified Wcli Contractor Dat
19
Br signing;this fortn, l herehr eertifi'that the xell(s)tvas•(ivere)constructed in accordance
?.is this a repair to an existing well: 13Yes or JgNo with 15.4 NC.4C 02C.0100 nr 15A NCAC 02C.0200 Well Construction Standardv and'hat u
;r rePnir..fli out known well construction information and explain the nature of the copy afthic record hac been provided to the well owner.
rau m:der•::_'remarks.ceetian o•onthe hack o(this form.
23.Site diagram or additional well details:
N.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You mac use the back of this page to provide additional well site details or well
,:onstniction,onh•1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
�ny � SUBMITTAL INSTRUCTIONS '
9.TotaI ivell depth below land surface: U� (ft.)_ 24a. For All Wells:_ Submit this form within-30-days-of-completion-of well--
n;a_:;e1r u�t:c list all depths ifdf#f renr(example-3(r%200'and 21,;1001 construction to the following:
i 0.Static water level below top of casing:- �L 1 (ft.) Division of Water Resources,Information Processing Unit,
:r::•: ,:,boor casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
:.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
2.Well construction method: construction to the following:
:g:r.rutap.,able.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 mail Service Center,Raleigh,NC 27699-1636
=r..Yield(-,pm) Method of test: Air Blow 24c. For Water Supply&Iniection Wells: In addition to sending the form to
017 ON the address(es) above, also submit one copy of this form within 30 days of
:_b_Disinfection type: Covine Amount: completion of well construction to
the cotmtt, health department of the county
whet;constructed.
:.;C-W-: North Carolina Department of Environmental Quality-Division of Water Resources Revised 22-101 t,