GW1-2022-00325_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
Coniractor Name �WKWII"DESCRIPTION
2135-A
1\L11 ContracrorCertification Number
TO
MUTERIVA
I ;S XITE2.aIf
A&F WELL DRILLING, AND PUMP SERVICE INC DIAMETER R THICKNESS MATERIAL
0 0 in.
Name
F
R 1NT Ilk €}Xi%TGB (G
2.\\ell Construction Permit#: FRO TO DUNTETEIt' TEUCKNESS MATERIAL
0 1
ivell construction permits(i.e.UIC.CounrY.State. Variance,etc.) ft. ft. in.
3.Well Use(check-well use): in.
i Water Supply NVell:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL__�
Ln,...\g­C L I I t L,ra 1. [3municipal/Public ft. ft. in.
L
ID-6cothernial(Heating'Cooling Supply) gResidcntial Water Supply(single)
z R. ft. in.
k'l1`.L1L!Stria!Commercial [2Residential Water Supply(shared) r ,aJ
r7kri,zation- FROM TO MATERIAL EMPLACEMENT METHOD k AMOUNT I
490 Non-Water Supply Well: ft. ft' sandmix poured
-Z- 3-N i on i Tort n a DRecovery
Injection Well:
ft, ft
D1Aci,.:ifcr Recharee
13Groundwater Remediation
A93'A"XWAVTL5PA1CK-1M A . . ....
aquifer Storage and Recovery E3Salinity Barrier CEMENT METHOD
Aquifer Test [3stormwater Drainage FROM ft. TO MATERIAL EMPLACEMENT
DExperimental Technology 13 Subsidence Control ft. ft.
n_G,:otherrnal(Closed Loop) 13Tracer J�xqq lof"
n- Cicothertnal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soill/rock type.gra
4.Date Well(i)Completed: 090)elllD#
na. Loration:Well rp,
_Rto�nxd
�;:ciii:v Owner Name ft. ft. 2 2 •ZUZZ
Facility ID#(if applicable) DEC
Ci*%. and Zip ft.
`R 5160MI
Coun!> Parcel Identification No (PIN)
in.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if ell field,one lat'101!-Q is sufficient) 22.Certification:
N W 11-29 AX
Permanent signature of Certified Well Contractor
6.is(are)the well(s) Permanent or Temporary Date
Ar signing this form.I herebv certify that the well(c)was(were)corwriveted in accordance
7.Is this a repair to an existing well: r1yes or �No vith J5.4NC.4C n2C.010n or' 15.4 NCAG 02C.0200 Well Constniction Standards and that ci
it;11A is repair,1711 out kno-A.-n well comtruction information and explain the nature of the copvqfthis record hav been provided to the}tell owner.
under:.2!remarks section or on the hack of thisfionn.
23.Site diagram or additional well details:
8.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
construcli I I QW-1 i. needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dn:!led: one) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ft-) 2-4a. For All Wells: Submit this,form within-30 days of-completion of well
1)n"Itiph,;relic list all�dep depths if d?fferent(aranip le-3(ev.2 00-'a nd 2 00') . ;�cfion-fo 6e following:---- I- - -
const ng.
'U.Static water level below top of casing: Division of Water Resoulr ces,Information Processing Unit,
;(01'Wlci is shove casitkg.use 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
1.Borehole diameter: 6 1 A
Rotary above, also submit one copy of this form within 30 days of completion of well
2.Well construction method: construction to the following:
t­ cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27609-1636
3s.Yi e I d(?,p in) L30 M Method of test: Air Blow 24c.For Water Suppl-v&Infection Wells: In addition to sending the form to
19 el the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection tvi3c.- Ch-4rine Amount: V completion of well construction tol tNe county health department of the county
where constructed.
ki
North Carolina Department of Environmental Qualit}-Division of Warer Resources Revised 2-22-2016