_Well Construction - GW1_20230315 (31)

%NTLI. CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
:on^,tractorName ,t FROM TO DESCRIPTION
2 135-A
\t 1l ell Contractor Certification Number
;;25:;t3!liT)R:CASII�G r.:tii:zltt-raserl%retls;flli�L�z ,,:,.:,.,, ,
A&r WELL DRILLING, AND PUMP SERVICE INC FRo.I To I DL4dIETER THICKNESS f MATERIAL.
0 o ft. S ft. to
��•mnanvName ' ..
(-I 1 M °'=i�=IRiVERGAsf'LU31;TI,fi3t� �keFu�l�rXo� �� •�
2.\\ell Construction Permit#: W 9/ Vv FROM TO 11DUMETEft' THICKNESS MATERIAL
... ..,.;::oniir;trie•+r<ri!rurts7ruction pe:wtitr li.e. L'lC Cnrrnrr.Srnte.F'orirnrce,ere•.) ft. f[.
in. i
.3.Well Use(check well use):
ft. ft. in.
!-rater Supply Well: FROM
SCREED _, t -...:,., n : •
FROM TO DIAMETER SLOT SiZE THICKNESS I MATERL4L
`Ag!'Cultural 1, unicipalllublic ft. i ft. in.
�tGcolhcrtuti(Heating:Cooling Supply) residential Water Supply(single) ft. I R, in.
a industrial Commercial DResidential Water Supply(shared) w3aR:GRO.LT .. -? ..' >w > , :_1 r I•"'I
rirritiation FROM TO MATERIALr EMPLACEMENT METHOD BA)IOCNT
Nor-Water Supply Well: � ft. A) ft' sandmix poured `
%ionitorinQ Recovery ft. 6J ft.
injection Well:
ft. ft
.fit;:i}er Recharee 13Groundw•ater Remediation k
tom•i'.� >19'SAD7tY`RFtikB=P.�At,K`tG
{` UL'ifcr$toraec and Recovery �Saliniry Barrier FROM TO MATERIAL y EMPLACEMENT METHODV
[ .-lquifer Test ` 13Stormwater Drainage
�E.xperimental Technology E3Subsidence Control
_IG,:othcrrnal(Closed Loop) Tracer 1.:2(1:DRILT7NG:1 t�tra¢fiai3dinoi%Islteetsilnec> tv i .
f Geothermal(HeatingiCooling Return) Other(explain under#21 Remarks) FRo>t TO DESCRIPTION(color,hardness soiVrock type.grain sire,etc.)
ft, ft.
�.Date Well(s)Completed Well iD#
5aa. Well Location: n � !F e
M I(ken BI'[l& rt, ft. y
ca!itc(.)u Name Facility ID=(if applicable) ft. ft.
a�.ir Ci:,.and Zip
03505
Parcel Identification No.(PIN)
St;.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
:(%%ell!icld.one iat lone is sufficient) 22.Certification:
b.Is(are)the well(s)dpermanent or 137femporay Signature of Certified Well Contractor Date
Br signing this fr,rm.I hereht•certify that the ire/l(,$)was(were)constructed in accordance
".is this a repair to an existing well: [3Xes or �o with I5A:\'CAC 01C.0100 or 15.4.NC.4C 02C.0200 Well Construction Standards and that a
is a rrnaw,till out known well construction hiformation and explain the nature o(the c'opr of lhis record has heen provided to the hell ovrrer.
N rtacr omen•::2!remark's.section at-on the hack ofthis.form.
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%veil
ousuuctipn,only 1 G\\'-1 is needed. Indicate TOTAL N(TVIBER of wells construction details. You mac also attach additional pages if necessary.
drilled:'c
QQ /
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C085 (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
nrr/t;pie wedlc list all depths ifdi((erent(example-3(4200'and @,;100') construction to the following:
- 0-Static-.a ter-level-below-top of casing:--- -40 _ -— -(ft.) Division of Vl'ater Resources,information Processing Unit,
:r ir:ri i.s shove rasing,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 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
2.Well construction method: construction to the following:
.. a:; :r.rotary.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR 1W:\TER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Yield(-,pm) SCIM Method of test: Air Blow 24c. For Water Supyly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
31i.Disinfcction type: lorine Amount: completion of well construction to the county health department of the county-
where constnicted.
::: :RC 'North Carolina Department of Environmental Quality-Division of Rater Resources Revised 2-22 2010