GW1-2022-00322_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
t ;
Christopher Greene 41C4 sw:4TERZONES
Well Contractor Name FROM TO DESCRIPTION •
ft. ft. �
2135-A ft. ft.
i
NC Well Contractor Certification Number 15::OUTER7CAS11.G-for-multi-easedltt'ells)'QR'1sI1YERC It a1010lic3tile 1. •. --`"
A&F WELL DRILLING, AND PUMP SERVICE INC FROM I TO DIAMETER THICKNESS MATERIAL
0 O ft. (5 ft. m
Company Name ' ��.GG++ &
i_16ANAER C SING OR";TUBING euEherinahclosed`Ioo
2.Well Construction Permit#: C) qFROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County.State. Variance,efc.) ft. It. in
3.Well Use(check well use): ft. tt. in.
Water Supply W1L 17:`SCREEN.
e .:.•,sr w:_• ,`, .>y , ' wkr e
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural JDMunicipal/Public ft. ft. in:
Geothermal(heating/Cooling Supply) LVResidential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared) 1g.GRQLT - ,y .. �x.`_"
Irrigation FROM TO. MATERIAL :EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 Q ft. R tt. sandmix 1; poured
Wv Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Remediation
A Se1NDiGRA��L,EACK:ifa"licablel
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEME\T METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control
Geothermal(Closed Loop) Tracer 20DRIbLINGLOG`(attach:addiNouaisheetstifnecessarv) ?`'^
,Geothennal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type.main size,etc.)
ft. ft.
ft. ft.
4.Date Well 20?�s)Completed: Well ID#
5a.Well Location:
Facility/OwnerName Facility ID#(ifapplicable) ft. ft. ear
Pave DEC 2 ft. 2ft.
2022
sical Address,City,and '� Q Q
O 1 4 1 1(J
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W /��y NOV f5 401100
6.Is(are)the well(s)dPermanent or Temporary Signature ofCcrtified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or eNo 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 copy of this record has been provided to the well owner.
repair under' remarks section or on the back of this fornf.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'Of SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2W 15 (ft-) 24a. For All Wells: Submit thin form within 30 days of completion of well
For multiple wells list all depths if dierent(erample-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: __._14 O (ft.) Division of Water Resources,Information Processing Unit,
IJlrater 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
13a.Yield(gpm) Method of test: Air Blow 24c.For Water Supply&Iniection Wells: In addition to sending the form to
Chlo me 12 the address(es) above, also submit 'one copy of this form within 30 days of
13b.Disinfection type: Amount: V completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016