GW1-2021-05482_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2135-A
ft. ft.
NC Well Contractor Certification Number ---
Cl 12 f IS ti�tw 1QIIl cabl
A&F Well Drilling Inc. FROM TO DIAMETER! THICKNESS MATERIAL
ft. ft. in.
Company Name
2.Well Construction Permit#: S20-0428 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coungt State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM tTO DIAMETER SLOTSI2E THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) -
' �° Oil
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20' fL sandmix poured
Monitoring ®Recovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
. .�'rrGl Ida e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
ry. w.
Geothermal(Closed Loop) Tracer „, c1t� t
FROM TO DESCRIPTION(color,hardness soil/rock e, rain size,etc.)
PAWIA
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: June 22, 2021 Well ID#
Sa.Well Location: ft. ft.
Suzzette McGinnis ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
218 Sandy Level Church Rd Bostic NC 28018 ft. ft.
Physical Address,City,and Zip ft. ft. uu 5
Rutherford 1648702 �
County Parcel Identification No.(PIN) InforM3111011 process
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W � 6/22/2021
6.Is(are)the well(s)ox Permanent or Temporary rgna ure of Certt ed ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or XJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For 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 well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:°"a(') SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 24a. For All Wells: Submit this:form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
-- 60' -- - -- '
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing-Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (O 9FIrn� Method of test: Airblow 24c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 32oz completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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