GW1-2021-05456_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
IN
Well Contractor Name FROM TO DESCRIPTION
2135-A `jt�it tt tt
NC Well Contractor Certification Number �raSCRg Ro " TO foHr��oDiETE
A&F Well Drilling Inc. FROM R THICKNESS MATERIAL
t 0 ft. 43' ft. in.
Company Name fi1L,CASLOR 7 $ Cr fl [alel> ��e /,„-
2.Well Construction Permit#: W20-0488 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): r`' r`' in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20' ft Sandmix Poured
Monitoring 13Recovery
Injection Well:
ft ft.
Aquifer Recharge ®Groundwater Remediation
�1110 %I/101
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage
ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed loop) Tracer % 7?RiG G=`" affc]idtltf t trees tf eary y %may%�////%%%
FROM TO DESCRIPTION(color,hardness soil/rock type, rain sire,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: May 20,2021 Well ID#
5a.Well Location:
Walter E. Hancock ft. ft•
Facility/Owner Name Facility ID#(if applicable)
286 Lawny Mill Rd.
Physical Address,City,and Zip
ft. ft.
Rutherford 165263201"i ttl14Y3tt ; // ///%/%/�% %% 01%/,!�`,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
N W V�O l UV)JL 5/20/2021
6.Is(are)the well(s) X Permanent or OTemporary Signature of Certified 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 XNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,,f ll 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 remarkv section or on the back ofthis 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ouei,l
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 325' (ft.
P ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 30' (ft.) Division of Water Resources,Information Processing Unit,
!(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) 10gpm Method of test: Air Blow 24c. For Water SuuDly&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: 36 oZ 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