GW1-2023-01738_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-1) For intemal Use Only:
ell Contractor information:
Christopher Greene -77
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FROM TO DESCRIPTION
ft.
2'35-A
•i;I C 1:'17artor Certification Number 1 —L- F,_.,,
.A&;:WELL DRILLING, AND PUMP SERVICE INC FRo� TO Di%%it-TER MCKNESS MATERIAL '
c 0 ft. ., �P ft. in.
^•na^.v Name
yCD4� 1
FROM TO D1.4 SSE THICKNESS MATERIAL'
:.1%ell Construction Permit#:. — , _..,
fl.
..,. ,rrptir,;hic•ucli constnrction permits(i.e.L7C.Cnrmtr.State. Fbrianre.etr.t '�� n.
3.weli l se(check well use): ft. ft. in.
.N aver Supple Well: 'O0iM .g!l1i. .. I
FR TO N D14ETER �SLOTSIZE THICKN MATERIALESS 4TERUf"
s.1_.:,;tittsral [DmunicipalrPublic ft. in.
71:cothcmiai(Heating Cooling Supply) &fResidcntial Water Supply(single) rt. rt. in.
i:,:r.stria:Commercial [3Residential Water Supply(shared) Vq .
i arahgn FROM ro MATERIAL EMPLACEMENT METHOD&A)10CNT
Non-Water Supply well: I O ft. a T z poured
'mot%Ionitorir.g Recovery ft. ft.
'n Jection Well:
Rechan-w 13Croundwater Remediation �.,.
A aitdr Storage and Recovery [Salinity Barrier �^FRON1 TO MATFRIAL EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
�. .
�,.:,,,,,hetTr,a:tCiosed Loop) Tracer r.]5�; .• -_. -_ - _-- - _ _ ��-
FROM t0 cec.
vj,:othennai i Heatin 'Coolin Return) Other(explain under:2l Remarks) ft ft
,.;ate well(s)Completed:1-30- 3 W'ei1iD# fr. ft.
-.:N ell I.ocation:
ft. ft. FHB s 7023
�--s•7 � rt. ft.
�amc Facility iD=(ifaPtlicablc) ft. ft. Itt�±
Mill t spolmsI fr. ft
d Zip 1— ft. ft.
Parcel Identification No.(PRO
titude and longitude in degrees/minutes/seconds or decimal degrees:
field,one fat lone is sufficient) 22.Certification:
s.'s(are)the well(s)dPermanent or 13Temporan signature nfCertified R'eli Contractor Date
Br signing 6n.,frn•m. 1 herehr cerri(i that the wellfs)was Iwerel cominicted in ucrordancr
this a repair to an existing well: [3Yes or JdNo uith 13.4 XC AC 02C 0100 or 13.4 NC4C 02C 0200 Well Construction Standards and that
u a a repair,fill nut known well construction information and explain the nature of the rop:of this record has been provided to the well under.
nine.'"":::i remurks section or on the hack nl'th&farm.
23.Site diagram or additional well details:
For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You mac use the back of this papa to provide additional well site details or well
_ :action,oniv 1 Gam`-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
one SUBMITTAL INSTRUCTION'S
C�i
;'dial well depth below land surface: y (ft) 24a. For All wells: Submit this form within 30 days of completion of well
list all depths it different lecample-3(a.200 amd 2 a 100I construction to the following:
t;.Static water level below top of casing: 100 (ft) Division of Water Resources,information Processing Unit,
..,.ahuve rasing.use'—. 1617 Mail Service Center,Raleigh,N'C 27699-1617
Borehole diameter: 6 1 A (in.) 24b. For Infection 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:
cable.direct push.etc.)
Division of water Resources,Underground Injection Control Program,
=OR WATER SUPPLY WELLS ONT-Y: 1636 Mail Sen ice Center.Raleigh,NC 27699-1636
?z.1 ield(Epm) Method of test: Air Blow 24c. For water Supply& Iniectiion Wells: In addition to sending the form to
Chlorine the address(es) above, also submit one copy of this forth within 30 days of
".sinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Qualin-Divsion of tt'nter Resources Revised 2-22-2()1 h