GW1-2022-09587_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene -
,
Well Contractor Name FROM ft. TO DESCRIPTION[t.
2135-A ft. rt.
NC Well Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC FROM I TO DIAMETER THICKNESS MATERIAL
ft. Q / ft. in.
Company Name 1
2.Well Construction Permit#: J 22- 2.�5FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State. i/ariance,etc.) ft, ft.; in.
3.Well Use(check well use): ft. tt. in.
"w" 17
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft, ft, in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. in,
Industrial/Commercial Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft ft sandmix poured
Monitoring Recovery ft. ft.
injection Well:
Aquifer Recharge ®Groundwater Remediation ....
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer
t;
FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: /-23-wU Well iD# ft.
Sa.Well Location: ' ft. ft. G i
1+,z 1 tx') ehrIAM ft. tt. OCT
Facility/Owner Name ��/ /� n Facility ID#(if applicable)
ft. ft.
ti3w 2ex QQ A� ILL �(1� ( ft. ft.
PJrD�i al Add•css,City,and Zip
ft. ft.
( _ 13
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
N W --A.—- q-27-2022-
6.Is(are)the well(s)�Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby c•ertifi,that the well(.)was(were)constrt,eted in accordance
7.Is this a repair to an existing well: [3Yes or %®No 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 of the c'opl'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:
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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:tax 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 different(erample�3@20^on a�)l00') construction to the following:
10.Static water level below top of casing: -T-V Division of Water Resources,Information Processing Unit,
11'warer level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1 A (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) Method of test: Air Blow 24c.For Water Supply& Injection Wells: In addition to sending the form to
t.J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: completion of well construction to'the county health department of the county
where constructed.
Fonn GW-i North Carolina Department of Environmental Quality-Division of Water Resources RetriSed 2-22-2016