GW1--02491_Well Construction - GW1_20240422

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Oni.:
:.Weil Contractor Information:
C ::stopper Greene
- .....,,,,,,,r\d:ne FROM ' TO DESCRIPTION
ft. ft.
2 35-A
ft. ft.
,A ('orsa.tar Certification Number
.-&F WELL DRILLING,AND PUMP SERVICE INC FROM TO 1 DIAMETER THICKNESS MATERIAL.
0
ft. QO it. in.
?.i!Eli Construction Permit#: I I Ei OD F..,")'t TO DIAME ' THICKNESS MATERIAL
.. .,..,: :reE construction permits(i.e. C/C.Count.State. G•ariance.etc.) U. ft. in.
.1.W ell t se(check well use): ft "'
toistegalgtt4hZ.Zitt.:44.W4
Vs a:erSupph Well: FROM TO j DIAMETER SLOT SIZE ' THICKNESS i MATERIAL
agt...:.a...... Municipal/Public ft. ft. i in, 1
;.:u;er^.:a:;Heating Cooling Supply) Residential Water Supply(single) ft. ' ft. in.
_ .,...>: .,.,Commercial Residential Water Supply(shared)
_: _at:or. FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT_
\.,,e-!later Supply Well: 0 ft. 40 ft• eandmlx poured
_\l,•.;itor,rg DRecovery ft. ft.
;:jection Weil:
ft.
' .e DGroundwater Remediation ft.
A ,age and Recovery Salini Barrier T`• x;' :> _ H
tY 4 FROM i TO< MATERiAI. L EMPLACEMENT METHOD
QStormwater Drainage ft. I ft. j
'ii\perimtrtai Technology ()Subsidence Control
ft. ft. I
"c.:.,,1.,..,.,..,a.;Closed Loop) Tracer
r! FROM TO DESCRIPTION'(color,hardness soil/rock type.gain air,etc.
:.:.0:1%.!nr.ai i Heating/Cooling Reeturnn)) ['Other(explain under#21 Remarks) ft. ft.
p
..;ate Well(s)Com feted: .0'2042Well ID# ft. ft.
ft. rt. V ..-
!lei,Location: ��ww`` U . ) 'L.i
1 ' �aCJ.7 f'
'�"'.,._\ '�Jls�om�11r ft. ft. A-PR 2 a 2024
C. arrie Facilit iI>(if applicable)
135 RAVA6 DRIve ft. ft.
a Zi ft. I ft. c,.
CIevs and (04505 m,a �.
.. Parcel Identification No.(PIN)
.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
.,:''c d.on,::at long is sufficient) 22.
Certification:
N W � ~ Tf
,.:sarr)the wellis)OPermanent or EtTemporar) Signature of Certified Well Contractor W
By signing this form.1 hereby certify that the wellt t was(were)constructed in accordant,.
-.:s this a repair to an existing well: ID'Yes or nE(No with 15.4.VCAC 02C.0100 or 15A.VCAC 02C.0200 Well Construction Standards and that c
. a;n,t;r.till-rut known well construction information and explain the nature of the copy of this record has been provided to the well owner.
-. -:•musks section or on the bath of this.form.
23.Site diagram or additional well details:
or 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 we::
;fit-: is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
. '.ctai well depth below land surface: 305 I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
.. . .._ . ali depths if different(example-3(4200'and 2@a 100') construction to the following:
S:aric water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit.
..• .:,.,‘,,e casing.use" 1617 Mail Service Center.Raleigh,NC 27699-1617
::.Borehole diameter: 6 1/4 (in.) 24b. For Injection Wells: In addition to sending the form to the address r._
Rotary above,also submit one copy of this form within 30 days of completion of
:2.!!eii construction method: construction to the following:
_ ..rear .earLe.direct push.etc.)
Division of Water Resources,Underground Injection Control Program.
Y tR 11 ATER SUPPLY/WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
?.:.Yield(gpm) Ill a 1X11 Method of test: Air Blow 24c. For Water Suotiv& Injection Wells: In addition to sending the form to
�Tf the address(es) above. also submit one copy of this form within 30 days of
..;J.Disinfection type: Chi tie Amount: ...3(0 O completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2°I r,