GW1-2022-00024_Well Construction - GW1_20221219

NVELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only
ell Contractor Information:
,rTistopher Greene
..'re:Inr Na:re 'r
FROM TODESCRIPTIO\
tt. ft.
2'35-A _
ft. ! ft.
nntractorCertification Number it►?:t ' 5'{±ilibiF
-8&F WELL DRILLING, AND PUMP SERVICE INC FROM } TO DLAMETER rH1cxNEss MArtR,>.
n O ft 10 ft. in. '
ill Construction Permit#: 101 lY FROM TO DLAMET THICK\ESS MATERIAL
perntits!Ce. C IC.Cnratt•,'.State. I'm'iam'�.ere'., ft• ft. in.
i �
.l%eii L se(check well use): ft. R. ! in.
NN ater Supply well:
•.FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
wtunicipal,'Public
ft. ft. in. ,
t(nolhcrnai I Heating Cooling Supply) R esidential Water Supply(single) ! ��
ft. ft. to I
[3Residentiai Water Supply(shared) 1>hllE3tiI : ;.:
�..'"".gut it)n FROM ! TO xATER1AL EMPLACEMENT METHOD&.AMOUNT
Ncn-N6ater Supply`,',ell: !1 ft. :� ft. sa^dnix poured
��iuniturir;g O
Recovery vJ ft. ft.
:nicction Nell: l �-
,,,, ft. i ft.
a, ar Bechar re [3Crroundwater Remediation
_ :,.`Or Swrage and Recovery Salinity Barrier FROM TO I MATERIAI. EMPLACEMENT METHOD
a afcr Test 13Stormwater Drainage ft. ! ft.
Mcsncrimentai Technology Subsidence Control ft. ft. I !
�-1r r tcm ,lClosed Loop) Tracer
FR0�1 ?O ' DFSCR TP r10N(color,hardness,soil/roek b m ye.grain sirs,ete.i
77...,.,n_- a.;Heart ngrCooling Return) 1 Othher(explain under T21 Remarks) ft. ft.
-. Date wells)Completed: /Qell ID# :r. ft.
ft. ft.
ikell L/ora�tio}n/:� f,1 I ^^ /� _
1l A l�!11,..J Oa I laey J I CP 5 (Q W I ft. ft. —
i I
- ,...., t he:ier Namc Facility lDa(if applicable)
a R.d[�LI 1 t�l..rLJ ft. ft. ' —
.. nd Zip
rCi l (0 5 Co OD 1
Parcel Identification No.(PiNi
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-,cid,one:at lore is sufficient)
22.Certification:
s,are)the well(s)21Permanent or Memporan Si'anarure of Ccniticd 11'eli Contractor Date
l3r.vgnin this(ravn. 1 herelrr cert!(i ;hut the veins! k'2s twerei c•owinec•ted a,cordant,
-. s this a repair to an existing well: ©Yes or 12(No .wh 15A ACAC 02C 0101)rr 15A NC.4C 02C.0200 Well Construction Srandarindc and ti: ;:
a repair.rill out knoxn xell construction inlnrmarion and explain the nature of the ,opi of thi.,ret ord has been provided ro the ice//owner.
rcmork.s section or on the hack oftltis fonrr.
23.Site diagram or additional well details:
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 wei'
;;u a:n;ctior only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessan.
j�
SUBMITTAL INSTRUCTIONS
; ;Ial%cell depth below land surface: 305 (ft-) 24a. For All wells: Submit this form within 30 days of completion. of%fi07!
:ciLs iisr ail depths(l'di(krent tetample-3(4..200'aan�d 2;a;-100') construction to the folllowine:
",tatic water level below top of casing: �V j (ft.) Division of water Resources,information Processing Unit.
..,.rs:;hm e casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
Borehole diameter: 6 1 A (in.) 24b. For Iniection wells: In addition to sending the form to the address in:Y::
Rotary above. also submit one copy of this form within 30 days of completion of wei
:_.Well construction method: construction to the following:
cnar,.rabic.direct push.etc.)
Division of water Resources,Underground Injection Control Program,
FOR%N ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Qh..' Yield(gpm) V Method of test: Air Blow 24c. For water Sunni•& Iniection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
:?b.Disinfection type: Ch Orine Amount: J completion of well construction to the county health department of the count.
<<itcre constructed.
: North Carolina Department of Enxironmentat Qualr,-Dirts;on of Wawr Resources Revised 2-22-20i t,