GW1--01556_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only: .
..V,ell Contractor Information:
g.
Christopher Greene - . - - ,y _ _--_ . , ,. .
r...,.e;a:\;n!t FROM TO µ,DESCRIPTION
I ft. 1 ft. I ( I
?35.A
Certification Number
AarELLDR!LLING,AND PUMP SERVICE INCTE L:.. ,
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ' 57 ft. '+in. .
:.W.:i:C ons• action Permit#•SIAl 24_ -o'( 4 C1 •---FROM TO-- --- -DiAMETL$ THICKNESS MATERIAL
— - -.;-1,,,,..,,--,"
...,., ,rl!,racetrecrfon permits(i.e.C7C.County.State.Yariance.etc.) fL ft. in. I
.'s..ail Z se(check well use) ft. ft. in.
_ FROM TO DIAMETER' SLOT SiZE TFIIOCN SS 1 MATERIAL
. ..,.,..:: OMunicipal/Public ft. 1 ft. in. 1
:.: ::-!er..,.,, catingg Cooling Supply) garResidemial Water Supply(single)
ommercial Residential Water Supply(shared) iiign ft ft en r.;: 1 s
__t:,:n FROM TO ( MATERIAL EMPLACEMENT METFIOD&.AMOUNT
-)'rater Supply Well: 0 ft. 40 ft. sandmix , ' poured
r_`s:•,:-:ror:n_ Recovery ft. • ft.
.:ion Weil:
' ft. ft.
....,.: Recsar: : (Groundwater Remediation 3
A.,.:., S:o cue and Recovery Salinity Barrier FROM ITO MATERIAL] EMPLACEMENT METHOD
`ter Test DStom[water Drainage ft. ft.
^..•-••en•:i Technology Subsidence Control ft. ft.
.,...:iosed Loop) riTracer ,,r,. x - . ., -. '" ,
.,rain rise i Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION.(eobr hardness saUrocic type grain size.etc.l
��yy,,�� ft. ft.
.:`,are Well(s)Completed:49"M'ts/oyq Well ID# ft. ft. j
ft. tr. ,
i.oc2 ion: g�a y.,71
ft, ft. 4 -£ fir (�,:
- • . ,1'•n::^e: \..ne /1� n� Facility ID=(if applicable) I ft. ft. MAR Leo
S [024
0 140 5 C I ure 1 PA ft. : ft.
.. ::}•,and Zip ft. ft. Dita� ,
. .tliler..paRcL.
(t5(04 _ 74rt�` '. .
Parcel Identification No.(PIN)
....Latitude and longitude in degrees/minutes/seconds or decimal degrees:
e'ci.one lat.lone is sufficient) . 22.Certification:
N
the well(s) Permanent or DTemporary • Signature of Certified Wcli Contractor Date
By signing this form.1 hereby certifi,that the walk)was(were)constructed in accord:nur
-._s:its a repair to an existing well: Dyes or filiNo with 15.4.vCAC 02C.0100 nr 15.4.VCAC 0?C.0200 Well Construction Standards and that:.
., ...nr.::ii sun known well construction lrtfonnatinn and explain the nature of the copy of this record has been provided to the well owner.
.. _. -:•.r,::r,'.•.s.section or on the hack of this forts.
23.Site diagram or additional well details:
ar Geo ar obe!DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or we::
_,.....-....on.on:y i LW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. .,. :,:Doe
//��
_
. SUBMITTAL L\STRUCTIO�S
.. ,,:z:well depth below land surface: Sob (fti) 24a. For All Wells: Submit this Iform within 30 days of completion of well
. .. . ...s•:all depths if different(example-3(a,200•and 2(411001 construction to the followine: I , '
C /
. -`•:u:�:-water-level-below-top-of-casing — 70 (ft.) Division of Water Resources,Information Processing Unit.-
.. . ....... rasing.use"-•' 1617 Mail Service Center.Raleigh,NC 27699-1617
.:._.ore o€e diameter: 6 1/4 (in.) .
24b.For Infection 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•wen:
._. s eii construction method:
construction to the followins:
. . ..... .,.c.a,three:push.etc.)
Division of Water Resources,Underground Injection Control Program.
:.:i ;i ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.Yield tppm) I+ method of test:Air Blow 24c.For Water SnpDly&Iniection Wells: Li addition to sending the form to
j jQ the address(es) above, also submit one copy of this form within 30 days of
..."'sinfccrior,type: Chlorine Amount: -!CJ Q completion of well construction toI the county health department of the cour.[I.
where constructed.
i
North Carolina Department of Environmental Quality-Division of Water Resources 1 R?s•icrr.•+_nn_uo:%