GW1-2022-00326_Well Construction - GW1_20221222

%�`ELJL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
Contractor Name FROM TO DESCRIPTION
2135-A
\C%\ell Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER i THICKNESS I MATERIA.I.
o
%'onipany Name
FROM TO DUMETElt THICKNESS t MATERIAL
2.1N ell Construction Permit#: I () L�![
aiia!Tficoble well construction permits(i.e.UIC.Couno..State, Variance,etc.) ft. ft. in•
ft. in.
3.V1 ell Use(check well use):
1 Water Supply Well:
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERLA.L Ll
Agricultural in.[2MunicipaVPublic
[]Gcothennid(Heating,Cooling Supply) Residential Water Supply(single) ft. ft. in.
lntiustriai Commercial [3Residential Water Supply(shared)
:21rrivation FROM TO MATERIAL EMPLACEMENTMETUnn
I Non-Water Supply Well: ft. ft' sandmix poured
DrVonitorin- DRecovery ft. ft.
'injection Well:
DAquifer Recharge E3Groundwater Remediation
DAqUifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
fAquifer Test 13Stormwater Drainage
::tExperimental Technology [3Subsidence Control
t Geothermal(Closed Loop) [3Tracer
aft&M INC_T#�l MESCR �il FROM DESCRYPTION(color,hardness,sollfrock tvpe,gmin size.etc.)
Cieothennal(Heating/Cooling Return) 0Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID# ft. ft.
7-
5a.Well Location:
t
n a%
Owncr Name Facility 1D#(if applicable) 2
/1^ ft. ft.
V, KA131 . 1 0 G,
City.and Zip ft.
ft
165U01
k Parcel Identification No.(PIN)
;h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
:`%%L!l fleki.one lat/long,is sufficient) 22.Certification:
N W
-.0-d-O
Signature ofCcrtified Well Contractor Date
6.is(are)the well(s),dPermanent or Temporary
Br signing ihisfiarni. I herehi-eer[iJ.i-that,the well(.�)was(were)constructed in accordance-
-7.is this a repair to an e,xistingwefl: 13Yes or EfNo with 15.4 NCA C 02C.Of 00 o'r 15.4 NCA C 02C.0-100 Well Construction Standards and that u
,;,:,usi,;a re,Pair,
Pair,fill out known well construction information and explain the nature of the Copy of thLi record has been provided to the well owner.
'Wit'1Wder-':_.-remurkssection or on the back of this fibrin.
23.Site diagram or additional well details:
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
1 GW_I is needed. Indicate TOTAL NUMBER of wells Construct
construction driLed:_� details. You may also attach additional pages ifnecessary.
�)Iy
drifled. SUBMITTAL INSTRUCTIONS
y.Total well depth below land surface: 24a. For All Wells—Submit_this.form-within.30-days-of-completion-of-well—-
T-Jist-,711-depths-ifdi(fep-ent texample-3@200-'and-2@1100D- :
construction to the following
10.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
X'Xiis above casing,use"+*' 1617 Mail Service Center,Raleigh,NC 27699-1617
'.Borehole diameter: 6 1 A (in.) 24b.For Injection Wells: In addition to sending the form to the address in
Rotary above, also submit one copy of this form within 30 days of completion of well
2.VVell construction method: construction to the following:
::-L,.az;gc r.roiary.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
Blow
13a.Yield(gpm) Method of test: Air 24c.For Water Suppiv& Iniectio.Wells: In addition to sending the form to
the address(es) above, also submit ;one copy of this form within 30 days of
73b.Disinfection type: glorine Amount: 00; completion of well construction to the county health department of the county
where constructed.
V
!7_.fill.