GW1-2022-09615_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Onlv:
1.Well Contractor information:
Christopher Greene
FROM TO DESCRIPTION
'�.1eil'ur.tnc;a-\an:e
2!35-A
rc rc.
\Y' \cll Contractor Certification Number
A&F WELL DRILLING, AND PUMP SERVICE INC
FROM TO DIAMETER THICKNESS MATERIAL j
o (t. rt. tn.
2.W ell Construction Permit#: ,_ =— D 143 FROM TO DCAMET THICKNESS MATERIAL
u'r r(nl>r'irahle❑4l construction permits(i.e,UIC.County.State. Variance,etc.) (t, fL in.
3.Well Iise(check well use): ft. R, in.
I Water Supply Well: S ' -i
FROM TO DIAMETER SLOT SiZE THICKNESS MATERIAL
�1L �g icuitural 13Municipal/Public ft. I ft. in.
IG otherutl(Heating Cooling Supply) IRcsidential Water Supply(single)
ft. i ft. in.
y�!ttutatriai Comnmcrcial Residential Water Supply(shared)
'irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
\on-Water SupplyWell: 0 ft. 20' ft• sandmix poured
MIA I on i ton n P
13Recovcry ft. ft.
Injection Well:
.O.Aquifer Recharge 130roundwater Remediation
.aouifcr Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquiler Test [3Stormwater Drainage ft. ft.
E\ncrimental Technology Subsidence ControlE
Geothermal(Closed Loop) Tracer
10cothennal(lieating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUroek h e rain size,em.)
ft. ft.
•:.Date Well(s)Completed: ° Well iD# ft, i tc.
Sa.Well Location:
ft. ft. P+•
j
Airy Owner\am Facility iDft(if applic i. n
OCT 2 1 2022
i 01 •i Y� ,YID 1 t Ao ft. ft.
Addms.a.City.and ZipDWOJWG
Parcel Identification No.(PIN)
I
--)h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
l ieid.one lat'long is sufficient) 22.Certification:
6.ls(are)the well(s)dPermanent or 13Temporary t@naru W tractor Date
Br signing!!rise form. 1 herehr cerio that the well(:c)was(were)constructed in accordume
7.Is this a repair to an existing well: QYes or VI(No with 15.4 \'CAC 02C.0106 or 15.4 NCAC 02C.0200 Well Construction Standards and that u
,r u;r.<is a repair•fill out known well construction information and explain the nature of the c'opt nfd this record has been provided to the well owner.
ymu�vndrr,._'remurks section or on the hack ofthis.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,. my 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
d:'.iit:d:'ss
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
i-",r n;cr.'!rf+ir;veils list all depths it'd erent(example-3(4,2000'atu:12�100� construction to the following:
U.Static water level below top of casing: (00 (ft.) Division of Water Resources.information Processing Unit,
. ,;::r:e, i is,ihove casing.use— 1617 Mail Sen-ice Center,Raleigh,NC 27699-1617 -
11.Borehole diameter: 6 1 A (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
i'.Well construction method:
Rotary above, also submit one copy of this form within 30 days of completion of well
construction to the following:
;i.e.aa,_er.,ratan.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
!FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: Air Blow 24c. For Water Suonh-& Iniection Wells: In addition to sending the form to
��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 count) health department of the county
where constructed.
North Carolina Department of Environmental Qualit%-Division of Water Resources Revised 2-22-2016