GW1-2023-00727_Well Construction - GW1_20230113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Christopher Greene ;ft.
�o DESCRIPTION
Well Contractor Name ft.
2135-A
NC Well Contractor Certification NumberA&F WELL DRILLING, AND PUMP SERVICE INC TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name /•� .. 0 @ I(1�-F1'�tF-
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
PP y FROM TO DL4METER SLOT SIZE THICKNESS MATERIAL
Agricultural 13 unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• ft• in.
Industrial/Commercial Residential Water Supply(shared) $
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft' � rL sandmix poured
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer t)
FROM TO DESCRIPTION(color,hardness soillrock e, rain size etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:J/ e 8 Well ID#
ft. ft.
55a1..Well Location
1 r 1 C ide C' J 1 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
290 Emerald. &rrald Ldk5 ft. ft. JAN 1 2023
Physical Address,City,and Zip ft ft. r _, r�r WIN
Rther ora� 101090'1
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 �' Av vyv Ame-9.90a.4
6.Is(are)the well(s) Permanent or Temporary Signature of Certified 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: ®Yes or J�No with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 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 tinder#21 remarks section or on the back of this form.
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
construction,gnly 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'one )
/�v�j � SUBMITTAL INSTRUCTIONS
9.Total'well depth below land surface: �y (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and1@I00') construction to the following:
10.Static water level below top of casing:® CD (ft.) Division of Water Resources,Information Processing Unit,
If water 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) 10 m Method of test: Air Blow 24c. For Water Supply&Iniection Wells: In addition to sending the form to
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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016