GW1-2023-02095_Well Construction - GW1_20230307

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
:•
Christopher Greene >;14"i�'A7'F1+::ZOItiES � .�. t:e�.-r_,�;��r_ 4,
`:‘;u c'nr,lraetoi Name 'r FROM I TO DESCRIPTION
ft. I ft. I
2 i 35-A ft. ft.
\; 11 ell Contractor Certification Number Mrf51 OU;EREA911 {for lit ltl-eikeliir; 7 QRl i " — }
A&F WELL DRILLING, AND PUMP SERVICE INC FROM I TO DIAMETER [ THICKNESS MATERIAL
0 ft. 5/ ft. Mtn
h'r•nna:1y Name �Cf
II.'II 11 /.{� "�1fr.:1:1NNER C:� G Ut: 'i'gl ax(;q '�11itnCt05 .�4OO '.,.'�.�:x K . r�
2. ,\ell Construction Permit#: S VV�W �a J I FROM TO DIAMETER" THICKNESS MATERIAL ~
... ,,i,applicable well construction permits(i.e.L'/C.County.State. Variance.etc.: ft. ft. in.
.3.Well Use(check well use): ft. ft. in.
?r17':SCREE'V .y.r..:4 4 M ., .. =45'.43- >`; 4?.. -':
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL .
;.\,.:cultural DMunicipal/Public ft. I ft. in.
�[Gct)thcrMni I Heatin Cooling Supply) MI Residential Water Supply(single) ft. ft. in. I
%lce:nstria:Commercial 0Residential Water Supply(shared) °=.18,GROt3T ,� ••. -.-. `-g, .:. .ai '
plrr igation FROM I TO MATERIAL i EMPLACEMENT METHOD&Al1OUNT.
Non-Water Supply Well: ' 0 ft. 31'1 ft* sandmix poured
\i
' onitoring DRecovery ft. O(LJ ft.
injection Well:
ft. ft.
LJ.at-uifer Recharue 0Groundwater Remediation
:.MSANDIORA1VE PACICfif "1icaltle)_= . :VA 4'aFRM .. .
E Auuitcr Storage and Recovery Barrier Baer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
F_(Experimental Technology ®I Subsidence Control ft. ft.
DGcot11crmal(Closed Loop) D Tracer °20 DR1LLSOi.LOG,(attae&'adduiaifatsWal t°necesas , " i
FROM TO i DESCRIPTION(color,hardness,soil/rock hype,grain size.etc.)
DGeothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: I .2I-2o23 Well ID# ft. I ft. j`-_Z.:-'. ,E•-. t; ::^.
ft. ft.
5a.Well Location: MAP, 7,.) 2023
Jt mm� PaiIse�, ft. I ft.
:.uity t.hr:ter.Na Facility IDS(if applicable) ft. I ft. Int`.i ;;;:::"1 P'i: 'r i t j1:,,, I
4 1 q imor i ah School Rd., ft. ft.
ae.'L\ddres..Ci:v.and Zip ft. ft.
' ui-i e r o►2.c1 I(6 55(n I o z .n.lA _..xi,. .. « _ _ -2.
..:a:. Parcel Identification No.(PIN) I
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
v.ell field.one latlong is sufficient) 22.Certification:
N W .7 I -24-2023
5.is(are)the wells) Permanent or Temporary Signature Well Contractor Date
Br signing this form./hereby certili,that the well(s)was(were)conwnuted in accordance
7.is this a repair to an existing well: ®Yes or 'No with 15.4.VC4C 02C.0100 or 15.4 NC4C 02C.0200 Well Construction Standard,and that a
AY:i.%is a repair.fill nut known well construction information and explain the nature of the copy oftiu.c record has been provided to the well owner.
ny:,rr•under.2.1 remarks section or on the hack of this forts.
23.Site diagram or additional well details:
N.For Geoprohe/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.
`""icti:.t row) _ SUBMITTAL INSTRUCTIONS
y�
9.Total well depth below land surface: 0 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
.',,•,n:d/five t:•ei c/is all depths ifditlerent(example-3@200'and 2®100') construction to the following: _
i 0.Static water level below top of casing: 40 / (ft.) Division of Water Resources,Information Processing Unit,
,,.., .r,ei is above casing.use"-' 1617 Mail Service Center,Raleigh,NC 27699-I617
-I.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
:2.Well construction method: construction to the following:
...., _ .:otar).cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR RATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
,3.a.field(gpm) 9 spun Method of test: Air Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of'
:31).Disinfection type: Chlorine Amount: l.J .1/ completion of well construction to the county health department of the count,
where constructed.
,:-a:1R'-: North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016