GW1-2022-09177_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I
2135-A f
rc. rt.
NC Well Contractor Certification Number y ,-�
� O.,Cf�E1t #tir n
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. ft. in.
Company Name
W I (J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: S V O
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
Water Supply Well:
ppY FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 63rResidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply shared
PP Y(shared)
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. sandmix poured
Monitoring DRecovery
Injection Well:
ft ft.
Aquifer Recharge 13 Groundwater Remediation
9Si1Tln1(s�R ` iffi 1
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT MF,THOD
Aquifer Test Stonnwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer � � ..,,'� ar gifi" � c //�
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location:
I
I0S £Zr��onza ez
Facility/OwnnerName L Facility IDD#�(ifapp licable) f. f. SFP 3 n 2022
N ukak,"Diaye e mble= CkaEV
ft. ft. y
Ph sical Address,City,and Zip q ft. ft. DINO OG
ilU 1 �� 7y
County IParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification
N W 62� G��rnsL� a a
6.Is(are)the well(s) Permanent or 13Temporary Signature of Certified Well Contractor ate
By signing this form,1 hereby cerlifv that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ®Yes or Jallo with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
!(this is a repair,.il/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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'ONE '
/�
� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi/ferent(example-3@200'and 1@100') construction to the following:
I
10.Static water level below top of casing: `7 (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) 5 aprn Method of test: Air Blow 24c.For Water SUDDIV&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: lorine Amount: qn2completion 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