GW1-2023-01702_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Onlv: 1
:.11 ell Contractor information:
CHristopher Greene : -Wit r
•,: ..:^ruc;or�a;t'.t 'r f _ T(l DrSCRIMO♦
2'35-A —
I
a Contractor Certification Number
&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DL%NIETER TIUCKNESS ?4aTERL%1,
ft. ft. _en.
Construction Permit r3l3 U31 `PROS1 TO DIAMET _ TffTC'KNESS f \faTERlAL ~
un/i ruusnrrction permits(i.e. C'lC.Cnunn.State. Ii7riance.etc.I ft.
Well 1 se(check well use): R.
+a:erSuppi? Nell: 9 q _ �.
FROST TO DIAMETERh SLOT SIZE THICICNTM MATERIAL
unicipahPtrblic t. ft..
ul
l 1
(,cathernuti i Hcating Cooling Supply) JaRcsidcntial Water Supply(single) I ft. ft. in.
Commercial E3Rcsidentiai Water Supply(shared)
:aiUtt FRO>1 TO MaTERI.AL I EMPLACEMLNTMETHOD&AMOUNT
\nn-N'ater Supply Well: ft. 311 ft• sandmix poured
:'lionitorir:e Recovery I ft. �[[J ft.
Injection Neil:
Recharue Groundwater Remediation „
.tS" } .
-.aliter Storage and Recovery Salinity Barrier FROM TO MaTER1.At. I EMPLACEMENT METHOD
5.ayuifcr Test 13Stormwater Drainage ft. ft.
aperimental Technology 13Subsidence Control ft. ft.
--i:oiliertr:al lCoosed Loop) 13Tracer ;. ¢
FROM TO —� DF,SCRTPTION(color,hardness,soiUrock r e•gm in sip,etc.i
.r:oditnnal i HeatinsjCooling Return) Other(explain tinder�21 Remarks) ft. lt.
- _
+.Date Well(s)Completed: 21-22Well iD#I r ft.
Well(s) ' ft• ,- y�
-.s.!Fell Location: i
ft.
ft. 2023
Facility iD (ifapplicablc) ft. ft. —
tr. ft.
?r:;
1
and ZIT, ft. ft.
�u ' er�'�►2rl 16 5561
Parcel Identification No.(PiN) _
_::itude and longitude in degrees/minutes/seconds or decimal degrees: L
ow iat long is sufficient) 22.Certification:
the well(s)dPermanent or Temporary signature o£Ccnified Well Contractor Date
B,. signitre this farm.I herehr semi6 that the wello)wits(were)constrru•ted in ace ordant
-.is this a repair to an existing well: [3Yes or JJNo with 13A,lC4C n_C.n1nn or 15.4.JC.4C 02C.02N)well Construction standard,end that
;s.r r rarr,F.1i oat known well construction information and explain the nature nl'the a opi o0hi,record has been provided to the Weil owner.
avi remark.+'serlion or on the hack o(this 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 well
,.n.ction,only i Gl!i'-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessan.
SUBMITTAL INSTRUCTIONS
-:;:al rsell depth below land surface: 305 (ft.) 24a. For .all Wells: Submit this form within 30 days of completion of well
, ...:s list all depths ifdiJferent(example-Rd..200 and 2A100') cunStnlction to the£ol loa ing:
u /
Static water level below top of casing: 4O (ft.) Division of Water Resources,information Processing Unit,
nor:casing.use—' 1617 Mail Service Center,Raleigh,NC 27699-1617
3orehoie diameter: 6 1 A (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24u
Rotary above. also submit one copy of this form within 30 days of completion of well
?.Well construction method: construction to the following:
...,sr..cable.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
1 field(gpm) GOM Method of test: Air Blow 24c. For Water Suool- & Iniection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this four! within 30 days o1'
D's;nPection type: Chlorine Amount: completion of well construction to the county health department of the counn
where constructed.
North Carolina Department of Environmental Qualin-Dix isior.of Water Resources Revised 2-23 2016