GW1-2021-04428_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2135-A
ft. ft.
NC Well Contractor Certification Number i -
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
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j in. SDR't1 1 PVC
C
Company Name
WaO -
2.Well Construction Permit#'S 030(P FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U1C,County,State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL�j/��
Agricultural Municipal/Public tt. ft. in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
Irrl anon 4k
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Ar O I'L 20, ft' sandmix poured
Monitoring 13Rccovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge 13Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer ,. '.__°.. af, ri'o ��'f.
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) tt. ft.
4.Date Well(s)Completed: - I Well ID# ft. ft.
5a.Well Location: ft. ft.
(_'edarCraV PoIni Ll.0 ft. ft. �p?s
Facility/Owner Name Facility ID#(if applicable) ft. ft.
a.Z Fawn I-!,I J D-i ye Rehear P cedar C reek
Physical Address,City,and Zip ft. ft. ��017 ti 4 erg`
Rulher f prd g5aco�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W elL�.�—
6.Is(are)the well(s)a Permanent or Temporary S gnature ofCcrtified Well 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 qNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standardv and that a
lfthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:ION'
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3o S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200and 2@100') construction to the following:
4 -1 10.Static water level below top of casing: 'a (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 Infection 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) 00 Method of test: Air Blow 24c. For Water Supply&Infection 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: 3LQ oZ completion of well construction to the county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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