GW1--05089_Well Construction - GW1_20240827

ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
. v.el Contractor Information:
ChrittpherGreene -,::,:- ' ' , „:.: --. . ---::--..,-'.---- ---,,,,,-,-,---_:_i: .:---,c,---....omix'..,•--: :
FROM TO DESCRIPTION
ft. ft.
2IZ-A i
i ft. ft.
.. :- :::-•(ern tazior.Number 01068010#100101elr''''''''Air - —
AlIF WELL tRiLLING, AND PUMP SERVICE INC , DLAMETER THICKNESS MATERIAL
fa ft. ft. in.
.4 .
X.f.lt-.7...:... '-,::::,: .- -.- ---''''''-- - -''-' - -,--..i:y,,:.7 .a1,7=:•.,c;V„,;.:_.
:.V,:i.Construction Permit#: ' FROM to • DAME . THICKNESS M A ERIA L
•- , .,': snliction permits(i e Z.1C.Count: State.Variance.etc., ft. ft. in.
r;.
' .•'•'..;.: ',ss,;check well use):
:...‘m-7----,;.........77:z,...,.---,., 1..:;.,7egif-- ,--,-..-C,!:7....',..-:-.. 7 --,.-,,...,4.:;,•.:.
.: .S;:ppi. Well:
i Fw.c-r,i ', TO ' i DIAMETER SLOT SIZE THICKNESS ; MATERIAL-,..-
(3 Municipal/Public ft. ft.
' in.
— -
_.:•.:..',-,:7-7•:::: a:'.:Ie Cooling Supply) iResidential Water Supply(single) ft. i
n. -L
in. I
°Residential Water Supply(shared)
.......
FROM 1 TO MATERIAL EMPL4CEMENT METHOD&AMOL\7_
s ;r.-W arer Supply Well: 0 ft.
f'• sandmix Dc,..rec
Recovery ft. I ft.
1
:::':.•:.:ion
ft. . ft.
. . ,
g °Groundwater Remediation
A .. and Recover!: rj Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
.......... ,
ft. .... %,.-..: •..:1"7;:s: 13 Stormwater Drainage ft 1
Technology ED Subsidence Control ft. ft.
.,.....
Ciosed Loop) Tracer '7"r "7"- ••• .7.-"---' . .. . . • -
. . _ ___. . . .
FROM TO I DESCRIPTION(color.hardness.soiVrock type.grain SiZe.,etc.,
.•.:..,.::-..irma.,i-ieating/Cooling Return) 0 Other(explain under=2: Remarks) ft. 1
-.;Lite;Lite' Completed:9'26,-202(1%ell ID# ft. i
ft.
I
ft. i ft.
''.... V,i::: : •Jcs.tor.: • 1
......-'. '.... 4.-s.._,
4 . rnin ijj ? - j-'
On — ft.
- ft.
-
7 2024
Fa..n:.:t) (DC(ifapplicab;c) la+ , ft. ft. AUG 2
_6 45 Lakeside Ittaa. Nebo tiarfivieto Peks5c7d ft. i
ft.
MCDtaad a_.
Parcel Identification No.(PIN)
5.-.....i.::.:.ide and longitude in degrees/minutes/seconds or decimal degrees:
:3:Ong is sufficient) 22.Certification:
N W
--444-#cao(9-4-ignature of Certified Weil Contactor
- - wellis)dPermanent or ()Temporary.
By Sighing this form.1 hereby ceriO that the wellio was (were,constructed,r...,,.......
- -. 7.,:s a repair to an existing well: °Yes or No with/5.4.VCAC 02C.0100 or ISA.VCAC 02C.0200 Well Construction Standard,
.„. ,.,......,, . ,.., so,known well construction information and explain the nature of the rapt.of this record has been provided to the well owner
.. : - ,,n..a k,section or on the hark of this form .
23.Site diagram or additional well details:
r GenprobefDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or-.‘e::
,.7fi
construction details. You may also attach additional pages if necessary.
..-.,...........).-..,,:-...\ . (31,\,-: is needed. Indicate TOTAL NUMBER of wells
'one,
SUBMITTAL INSTRUCTIONS
,. ::::::::well depth below land surface: 285 (ft) 24a. For All Wells: Submit this form within 30 days of completion of weli
- .....:,.,'ail depths if different(example-34200 and 2'4100'1 construction to the following:
••-.:-Lin water level below top of casing: ri 0 1 (ft.) Division of Water Resources,Information Processing Unit.
1617 Mail Service Center,Raleigh,NC 27699-1617
• lic;:--;:hole diameter: 6 1/4 (in.) 24b. or 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::
.2 v<el:construction method: construction to the following:
, .„,..:- :.,-:".7:. :.?..r.e.Ct....VC:Push.etc.) .
Division of Water Resources,Underground Injection Control Program.
-:•.;!•?.`+ A TER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
ir Blow. ',cid feprn; Method of test: A 24c. For Water Suvolv&Iniection Wells: In addition to sending the form :o
ic the address(es) above, also submit one copy of this form within 30 days of
--....- --,:-. :Noe: hlorine
Amount: completion of well construction to the county health depanrnent of the count.
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2"):s