GW1--04673_Well Construction - GW1_20230721

WELL EL•L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Christopher Greene is � " -E:W ....
FROM TO r DESCRIPTION
:: i on:f ctor Name f2. ft.
2135-A
ft. ft.
i
\. 11 e''Contractor Certification Number ,... - r,,_ ,,_
A&F WELL DRILLING, AND PUMP SERVICE INC FROM { TO DIAMETER I THICKNESS , MATERIAL
e Q ft. ft. ,in-
Name ''> ..p''''''.
2. 1C ell Construction Permit#: W Q3 ®0 1 Co FROM TO I DLAMET THICKNESS I MATERIAL
....aynl[;u•:d well construction permits(i.e. L'1C.Catmn'.State, Variance.etc.) ft. ft.
in.
3.W ell Use(check well use):. ft, ft, in.
tM ci �x.,� P',£v i axe'. 1 f
t aier Supply Well: £ �r x x < .. a el, t .,_...< a
FROM 1 TO DIAMETER SLOT SIZE THICKNESS i MATERIAL~
.V_r'c.:.tur;:' 0Municipal/Public ft. I ft. in. I
7, 5;(icotlrcr)s:t Heating Cooling Supply) sResidential Water Supply(single) ft, I ft. in. I
I
.:,:.triz Cnt:t:rcrral Residential Water Supply(shared) , , ..,,,4:",z? .. , ',,,," ,:r. :....,- ,.4>:w
;- _ation FROM I TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT !U.
Non-Water Supply Well: 0 ft. 1 ft. I sandmix poured
\ionitor:..g D Recovery ft. ft.
l.tection Well:
ft. ft.
_i.A. Recharge , 0 Groundwater Remediation vv��
.. C A:c.:tcr Sto:aue and Recovery DISaliniv Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
tAc::ter lest DStomtwater Drainage ft. ft.
7 Experimental Technology DSubsidence Control ft. ft.
e(:,:iotier t Closed Loop) 0Tracer < i Sal` ' x. _
FROM TO I DESCRIPTION(color,hardness.snit/rock type._rain sift.etc.)
i� Gcothe m)ai i cicaIing?Cooling Reeturn) Other(explain under n21 Remarks) ft. ft.
4.Date 1Vell(s)Completed:?—11" Well ID# ft, ft,
Well Location:
ft. ft.
� t ft. ft. , v cF V�r)
r' 1� !A 0! . �e R�7E 90 ft, ft. a.>
::t C)\rncr Name Facility IDS(if applicable) JULft. ft. U 1,d i 201.3
.•,:;::' -tddre,o,City.and Zip ft ft I I1fOf t�rtu gl
Parcel Identification No.(PIN) •
...Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•.cc!'irld.one:at lone is sufficient) 22.Certification:
N
WG Pr I ® .
e(ate)the well(s) Permanent or Temporary signature of Certified Well Contractor Date
Br signing this form,I hereby c•ert(6,that the)1:ell(.c)was(were)constructed in accordtnrc
-.:s this a repair to an existing well: DYes or.EgNo with 15.4.VC4C 02C.0100 or 15.4.NCAC 02C.0200 Well Construction Standards and thin a
..,I.,a i_;natr.rill-'at known well construction information and explain the nature of the copy of this record has been provided to the well owner.
,.•4r •;•mark.,section or on the hack ofthi,c form.
23.Site diagram or additional well details:
For GeoprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
::::)sttaetio:t.onlyi OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
' `as
SUBMITTAL INSTRUCTIONS
+.Total well depth below land surface: 1 W 5! (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
,:::::.........:,,as iist all depths if different le.rample-3(4200'and 2@100') construction to the following:
0.Static water level below top of
casing_ COO ) Division_ofYaterResources,_Information_Processing-Unit.
,:•r. c-:,:hove casing,use"4-"— -----
1617 Mail Service Center,Raleigh,NC 27699-1617
''.Borehole diameter: 6 1/4 (in.) 24b. For Infection 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.Weil construction method: construction to the following:
.rota cabie.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYP� WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636
,:a.Yield(gpm)C9/Qp1l Method of test: Air Blow 24c. For Water Supply&Infection Wells: In addition to sending the form to
�d the address(es) above, also submit one copy of this form within 30 days of
:_1).Disinfection type: Chlorine Amount: 34 completion of well construction to the county health department of the county
where constructed.
m•: North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016