GW1--03253_Well Construction - GW1_20240528

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
..W ell Contractor information:
^-s,opher Greene 3-. $
•,•,,;...\,;: FROM TO T DESCRIPTION
ft.
2 35-A
ft. ft.
I t I...C:t.to C erti ication Number r ... .. - _-
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO ' DIAMETER THICKNESS \1s FR!s:
C . ft. ft. , in.
:.N%ell Construction Permit#: Ski 23/211- O`--' •3 t FROM I TO • MAME • THICKNESS m ATER:AL.
• ..,,. .rrl!construction permits fi.e. LTC.County.State.Variance.etc.) It. ft. In.
«ell t se(check well use):
er Suppy Well: s-x ``.: > n.> , ;w :."- _ ._
FROM TO DIAMETER SLOT SIZE THICKNESS : MATERIAL
'vlunicipaUPublic ft. ft. in.
, ,.. Heating Cooling Supply) esidential Water Supply(single) ft. ft. in. a
.. ...•.. ,, :•-crcial DResidential Water Supply(shared)
K
"7:::-:u.:i:on FROM TO MATERIAL i EMPLACEMENT METHOD&4MOt:N1
s:;n-Rater Supply Well: a fL ft. sandmlx I pcuted
\':•;:rtr:c DRecovery ft. I ft. t
r.ection Well:
ft. ft. f
3‘..':: !,:r Recharge QGroundwater Remediation
ti
A..:.,:! *Storage and Recovery QSalinity Barrier FROM : TO MaTER Al , EMPLACEMENT METHOD
...cr Test QStormwater Drainage
ft. ft.
.xper;trerrai Technology DSubsidence Control ft. ft.
.e.:. Closed Loop) Tracer ., cz''YT'-'"'tik
..r . Closed
Heating/Cooling Return) [$Other(explain under#21 Remarks) FROM ' TO DESCRf�T10N icn)oc hardness.soil root ape,_rain.c.e.ere.__
.uth�. i
I ft. ft.
,.:ate Weii(s)Completed:5-2I-2024 Well ID# Ii ft. ft.
_. I ocat c,n �tJacob Me Ilto^1 ft. ft. — S�
Facility IDe(if applicable) ft. ft. '1A`I tr 5 LeZ4
I1(D3 POI Iis Rd Ellen OM ft. ft. ; �.
Ir`• � t .
ft ft
'Rah erftrd ^ TBD Par- 3&64$2
Parcel ldenti cation No.(PIN)
.. :::1de and longitude in degrees/minutes/seconds or decimal degrees:
c.o-.c:at long is sufficient) 22.Certification:
N W G ��...6 Yay ai,
:he well(s) Permanent or Temporary Signature of Certified R chi Contractor Date
Br signing this form.1 hereby certi6 that the xellrst was(were)conctn,cted in accnrden;,
7::N a repair to an existing well: ['Yes or liNo with 15A. CAC 02C.0100 or 15A.VCAC 02C 0200 Well Construction Standard.and:hot..
•.. era:,•.riii-no known well construction information and ecplain the nature of the copy qt.this record has been provided to the well owner.
:.:,•: r:_:.•,,tari:.c'ection or on the hark 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::
`: :.a: ih.a6 i OW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
(t)405/ SUBMITTAL INSTRUCTIONS
:eta;well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
.. . .,--s cst all depths if different tetample-34200'and 2'a ioo') construction to the following:
. f:ate water level below top of casing: SO/ (ft.) Division of Water Resourc
es,Information Processing Unit.
wing.ase 1617 Mail Service Center,Rakigh,NC 27699-1617
::.Borehole diameter: 6 1/4 (in.)
24b.For IniecBon Weil: 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 we'::
::.R ell construction method: construction to the following:
. . _ ... .-c..t.d:rec:push.etc.)
Division of Water Resources,Underground Injection Control Program.
:1R N1 A T ER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
.Yield(rpm) 5( Method of test: Air Blow 24c. For Water Supply& Iniection Wells: In addition to sending the form to
RT1t the addressees) above, also submit one copy of this form within 30 days of
J.Disinfection type: C, urine Amount: completion of well construction to the county health department of the couni
where constructed.
•• North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2:::