GW1-2022-09586_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: p
Christopher Greene `
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2135-A
ft. ft.
NC Well Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
0 0 fL ft. in.
Company Name /a.
!�
2.Well Construction Permit#: SUl/ I D �to)
�/o 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):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. tt. in.
Industrial/Commercial 13Residential Water Supply(shared)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT"
Non-Water Supply Well: ft. ,� ft* sandmix poured
Monitoring Recovery
injection Well:
Aquifer Recharge [3Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO I DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
ft. ft.
4.Date Well(s)Completed: Well iD#
5a.Well.Location:
Carlos it Jnnz6JJeZ f` OCT 2 12027
Faacility/OwnerWName L Facility IDD#(ifapplicaabblee)) ft, ft.
N N kqr _D ,e Cj l ap
=—fie t L ft. ft. v
OJWG
Ph sical Address.City,and Zip
l(J 1 ' 1 /7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient) 22.Certification:
W 6 L 64aazzi 9 a s
6.Is(are)the wells)fgPermanent or Temporary Signature of Certified Well Contractor ate
By signing thLc form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or [INo 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 ofthe copy of l&v record has been provided to the well owner.
repair tinder#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
R.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:1011 1
30 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: I U (ft.) Division of Water Resources,Information Processing Unit,
1/water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Iniection 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
139.Yield(gpm) m Method of test: Air Blow 24c. For Water Supply& Iniection 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: AR ain,2completion of well construction to the county health department of the county
Lof where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016