GW1--03721_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
..V.eii Contractor Information:
:,�-'s:opher Greene ,
. ...,.\ FROM ' TO . DESCRIPTION'
ft. ft.
2 35-A
ft. ft.
s: i'or:-:it:orCendlcation Number ._.....,y
.-&.WELL DRILLING, AND PUMP SERVICE INC FROM TO T DIAMETER T CKNESS MATERIAL
oft. 50 ft. in.
S�123/2 - 0 cos T_ _ ATE I L
:. ,ci:Construction Permit r.: FROM TO DtAvtEr rTttCKVEss MATERIAL
•. .....; . i fU(t
•. ',us , ior,permits lie. L'IC.Count(.State.Variance.etc.) ft. ft, in.
'..v.ail 1 se(check well use): ff. ft. in.
,, FROM TO DiAMETER 1 SLOT SIZE THICKNESS MATERIAL
\ r:::..:..r„ °Municipal/Public ft. ft. , in. 1
•.,...,.. .;:;Heating Cooling Supply) �Res:dential Water Supply(single) ft. ft. in. 1
z:Ca'- "crctai °Restdential Water Supply(shared) .. g ,
-c:JL FROM TO I�MaTERI'L EMPLACEMENT METHOD&4MOC\'_
'.;n-VLater Supply Well: 0 ft. j �i('1 ft. i sa�dnix poured
, ,:1�,r::g Recovery ft. +, �►V ft.
ion Well: l
cow ft. ft.
; :'.::':2• Rec-arge DGroundwater Remediation _..,_.._:,... ,_-
A. .r.r S;.)raeo and Recovery °Salinity Barrier FROM TO : MATERIAL I EMPLACEMENT METHOD
......_., 0Stonnwater Drainage ft. ft.
•:7xperitrertaiTechnology r3Subsidence Control ft. ft.
.. ••.....,T.:a.i Closed Loop) OTracr. _.
..:.O:i ii;;.^.:`;d.1 ti.atin COOhn Return) FROM E TO DESCRIPTION(color.Yardarm,sof/rock type.grain size.etc.;
gi g [,}Other(explain under#21 Remarks) ft. ft.
..Date Well(s)Completed:5-0-43044 Well IDU ft. ! ft. 1
. .c:.Location: ft, ft. —T
4 1 love(gee Jr I _ ft. ft. �L`� . ,V ��,
Facility 1D=(if applicable) ft. ft. W Jt tYt
Ri G P. DRi1/P 1�eJot N L Sub ft. I ft. Y J 2024
a
"Rutherford 140 3 8?11-8 ,,... .,-._
Parcel Identification No.(PIN)
._. :.cia and longitude in degrees/minutes/seconds or decimal degrees:
..;:at or. is sufficient) 22.Certification:
N
W 4, )/r-----.- 5-21 -20 24
'%;.f :ha wellls)'Permanent or 13Temporary rgnature ofCenificd ell Contractor Date
By signing this form.I hereby cernfi that the swills)was/were,constructed in actin—dam,
-_:.-"'a repair to an existing well: DYes or ErNo with 15.4.'CAC 02C.0100 nr IS.A.VCAC 02C.0200 Well Construction Standardds and that o
.. ii'our known well construction information and explain the nature of the copy of this record has been provided to the well owner.
_ .marks crtion or on the hark of this fnnr,
23.Site diagram or additional well details:
nr Gecprobe!DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page:o provide additional well site details or we::
• : U W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. ..: • one
�Mf SUBMITTAL INSTRUCTIONS
. .,,.z:t,cii depth below land surface: S7GV 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
. ,.s.•ail depths if different(example-3;d,2 00'and',,gioo) Construction to the following:
(,] /
. s:anc water level below top of casing: L� (ft.) Division of Water Resources,Information Processing Unit.
:,,: rasing.ase 1617 Mail Service Center,Raleigh,NC 27699-1617
.:.'sr:rehole 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 we::
.:.:i ell construction method: construction to the following:
..,.,.d:rec:pus::.rc..
Division of Water Resources,Underground Injection Control Program.
.:R'th-tIER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
.1 ieid;gpm; 15 Qpm Method of test: Air Blow 24c. For Water SuDDiv& Injection Wells: In addition to sending the form to
athe address(es) above. also submit one copy of this form within 30 days of
:sinieertor.rype: Chlorine Amount: 3( completion of well construction to the county health department of the cour.t!.•
where constructed.
• • • North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.2i-'n-t,