GW1--06488_Well Construction - GW1_20231002

WELL CONSTRUCTION RECORD (GW-1) For Internal USe Only: �`
I.Well Contractor Information: N !
Christopher Greene t
i:.n:rs.ur,Name - TO DESCRIPTION
• ft. ft.
2135-A
ft. [ .
. 0
r (nrractor Certification Number
''a _
0
A&F WELL DRILLING, AND PUMP SERVICE INC FROM I TO DIAMETER, THICKNESS MATERAA1.
ft. 1 Q• ft. in, i
:.14 21l Construction Permit#: --- FROM- TO I DIAMETL - ---- THICKNESS' . i•.MATERIAL' -
....... rti;,,•,:rir.w!;,oncn•r%rion prrnuta(iar.Z'!C.ConiFn-.'State:Variance.etc.) ft. 'ft.
3.Hy ell Lse(check well use): ft. ft. in.
2:er Supply Well: FROM 1 TO DIAMETER SLOT SIZE i THICKNESS i MATERIAL
V•<:':-•':•Ura 0Municipa!/Public • ft. 1 ft. in.. I i
t ieethem:ai:Heating Cooling Supply) DResidential Water Supply(single) 1 1
PP Y g ft. i ft to l
7. .s..:ai:-tal Commercial OResidential Water Supply(shared) ..40403m,m to,y",,,t„ , :,. _ •Y ,.T.=ram:..., .,:, :
:Gatlin FROM TO 1 MATERIAL EMPLACEMENT METHOD&AMOUNT
\•rn-hater Supply Well: 0 ft. .90, ft. sandmix ; poured
I:\icmitonn•_ DRecovery ft. ft. ,
in.ection Well:
ft. ft.
..-.t::i!er Rccharue Groundwater Remediation I 1 I
.A::ttiter S:ora'ae and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
' .aquifer Test . QStotmwater Drainage ft. ft.
i.
.xperin-lent&Technology DSubsidence Control ft. ft. 1
_iGco:h:e7:;a:(Ciosed Loop) Tracer 4." •
`m'?, FROM - TO DESCRIPTION(color,hardness,soil/rock type._rain size.etc.)
�,,:.;othcrana1 t HeatingiCooling Return) 0Other(explain under R21 Remarks) ft. ft.
_,.Date Well(s)Completed:q'2(0-2O2 ,.ell ID# ft, ft.
.i.Well Location: ft. ft. r-. --- a it 5""
Je.-pc Be If lakleR, ft. ft. z C k.., A l
f E...
\:ern ' Facility iD=(if applicable) •
ft. ft. OCT 92 2023
e t Moue kl b t,ndaIe. ft. ft.
At ire.:,.(.'i; and Zip ft. ft. Itli --,..c�s'ioz er:-,7 4a:-�4 Ut„a
Parcel Identification No.(PIN)
•
Latitude end longitude in degrees/minutes/seconds or decimal degrees:
•: s,ii 11:ld.one:at long is sufficient) 22.Certification:
N "' ..,44P.-.7—s� � Z Zbt23
.'siar;;the we11(s)'Permanent or Temporary Signature of Certified Well Contactor ate
By signing this form. I hereby cernh'that the we1/Gi)was(were)constructed in ac•cord:a:cc
-.:s this a repair to an existing well: DYes or PiNo with 15.4:\-CAC 02C.0100 or 15.9.NC.4C 02C.0200 Well Construction Standards and that a
repair.rill nut known well construction information and explain the nature of the copy of this record has been provided to die',well owner.
...•• antic.=:^:.;•marks section or on the hack of this form.
23.Site diagram or additional well details:
N. or treoprobeiDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or we!!
;.::s:r-:ctit)•n.only i G�:-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
one' SUBMITTAL LNSTRUCTIONS
.."Total well depth below land surface: 5
t3a (ft) 24a. For All Wells: Submit this form within 30 days of completion of well, ..,its list all depths ifdijferent(example-3(a�200•and 2 I00) construction to the following:
-
i O.Static water level below top°Leasing:. `-i"O 1 (ft.) Division-of-W'.ater_Resouresrinfotmnation_P-rocessing_Unir-
., ..:::;ia,w casing.use"=•' 1617 Mail Service Center,Raleigh,NC 27699-1617
6 1/4 !'
::.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in=4a
Rotary above, also submit one copy of this form within 30 days of completion of well
.-.:Well construction method: construction to the following:
- ....tars-cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
5• :t.Yield(gpm) IC) dpl71 Method of test: Air Blow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one,copy of this form within 30 days of
-.Disinfec fort type: Chlorine
Amount: 34 off, completion of well construction to the county health department of the county
0 where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 22-2(116