GW1-2022-09432_Well Construction - GW1_20221017

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Christopher Greene IE�. - • o1M �
FROM TO DESCRIPTION
Well Contractor Name ft. ft
2135-A rL rL
NC Well Contractor Certification Number I�t[Q.i�rERiG4SIN(s�fo't m iiltr caSed4ivelLSl`.E}1L� ''I�1 """' e
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICIQIESS MATER1,4I.
fL fL 1tn
Company Name
��—s-�a —flq f� �tslx� �si�rcrairzsl��s en -,
2.Well Construction Permit#: FROM TO DIAMETER THIC"IESS NUTERIAL
Lisr all applicable trell construction permits(u.e.WC.County,State. Variance.etc.) ft ft. I in.
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3.Well Use(check well use): ft• ft in.
Water Supply Well:
FROM I TO DU METER SLOT SIZE THICKNESS MATERIAL
_Agricultural unicipal/Public ft. ft, in.'DGeothernial(Heating/Cooling Supply) RRXesidcntial Water Supply(single) ft. ft. in.
RIndustriaUCommercial Residential Water Supply(shared) af8.@51fe,
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. sandmix poured
Monitoring E3Recovery ft. fL
Injection Well:
•ft. ft.
,Aquifer Recharge [3Groundwater Remediation
95`c►tA7GR%1� Lx1'ziCltif%d Lcalule)
LjAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:,Aquifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control ft• ft•
Geothermal(Closed Loop) 'Tracer C 2U'�I Rf1 T S GTi t) "fx`itaeh'addii onalisi>eets( ia£ceasark'" �"" -�..:
Geothen-nal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type_etain sim ete.)
ft.
4.Date Well(s)Completed: ell ID# ft. ft.
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Sa.Well Location:
ft. ft OCT „ —
Facilit i0wner Name—L Facility IDr`#(if applicable)
'}•,r,�
ro �; Uril
Physical Address City,and Zip �T ft. ft. I
• 0531455 -�ar�Rrrti�Ksl K��� �.•� •-� : �� �;��,:ice
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4org is sufficient) 22.Certification:
�..- ID-
6.Is(are)the weU(s)6dPermanent or,[3Temporary Signature of Certified Well Contractor Data `• 7r
By signing this form,1 hereby certify that the it-ell(s)was(were)-cofftructed'in accordance
7.Is this a repair to an existing well: QYes or R�No with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that u
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair raider T 21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.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 NUti1BER of wells construction details. You may also attach additional pages if necessary:
drilled:'°" I
'1 b 5' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft) 24a. For All Wells: Submit this form within 30 days of completion of well
iror multiple welly list all depths if different(erample-3@200'sand 2 aC3100D constriction to the following:
10.Static water level below top of casing: `7 O, (ft.) Division of Water Resources,Information Processing Unit,
If::ozcr level $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
.Well construction method:
Rotary above, also submit one copy of this,form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Up derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I32,Yield(gpm) Method of test: Air Blow 24c.For Water SuDDIv&Iniectiou 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: C brine Amount: completion of well construction to the county health department of the county
where constructed.
Fomi GP,'-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016