GW1-2023-02710_Well Construction - GW1_20230411

WELL.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Greene
FROM TO DESCRIPTION
t\eP Contractor Name
2 i 35-A
ft. ft.
\t'\\ell Contractor Certification Number
�yS�dfI,1'EIY:(,�Ai3I1�fi.Y�foadlstrt-casG'glfii �?ItP_ -z-
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DLANIETER THICKNESS I MATERLAL
0 ft 11 ft. in.
l'onnpanv Name ✓ _ ..
�Cr'1 ��..��CCff ;'14��A�ER'Cre�Slr!k�-tllta3�'.$�11t�r" ..,, v .„ ;, ... -,;r "��,'�,•�.',$r ?..:�`-4—'
2.Well Construction Permit#: SWa 1 r 0a00 FROM TO I DL4,SSET9K- THICKNESS MATERLaL
List till applicable well construction permits(i.e.UIC.County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
{-$t? ,w".'^•e`` ;e6:.�'` ..,.,x,rt�*,..+«,L :,a:r ..�#tM.. sw,:y,,.�ikr_ -.{Si
i Water Supply Well: FROM TO DL4METER SLOT SHE THICKNESS MATERIAL
Agricultural [3 unicipaL'Public ft. , ft. in.
Geothermal(Heating/Cooling Supply) Kficsidential Water Supply(single) u. ft. in.
Industrial Commercial 13Residential Water Supply(shared)
-
Innation FROdt TO MATERIAL EMPLACEMENT d1ETHOD&ANIOCN'T
Non-Water Supply Well: ft. ft. sandmix poured
n lonitorine Recovery
Injection Well- ft. ft.
Aquifer Recharge IlGroundwater Remediation `
Aquifer Storage and Recovery 13Saliniry Barrier FROM TO MATERIAL EMPLACEMEN'rMETHOD
A uiter Test Sto mwater Drainage
Experimental Technology Subsidence Control
Gcothermal(Closed Loop) 13Tracer :ail,1yr213 t IL+t ,I:{1 ei to i _x #rr
( g ) Other(explain 21 Remarks) FROM TO DESCRH'TION(color,hardness,soiltrock e, rain sirs,etc.)
Geothermal(Heating/Cooling Coolin Return) ^^ ex Iola under# ft. ft.
�.Date Well(s)Completed:-0l���'JQ Well ID#
3a.Well Location: ^ fr.
A
acilincOvvnar Name Facility ID"T(if applicable) ft. ft. t
s 2023
ft. ft.
i'hysical Address,City.and Zip
�� - 1160 4)7��� �(
7,
c"ota)n' Parcel Identification No.(PIN)
Ab.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
61'well field.one lat9on_is sufficient) 22.Certification:
W
6.ls(are)the well(s)dermanent or 13Temporary Signature of Certified Well Contractor Date
gv signing this frrm,1 herehr c•eriffi•that the well(s)was(were)constructed in accordance
i.Is this a repair to an existing well: QYes or S'No with 15.4 NC4C 02C.0100 or 15.4 NC.4C 02C.0200 Well Construction Standardv and that a
It this is a rEpain.flll out known well construction injormatlon and explain the nature ofthe cop)'gfihis record hav been provided to the well owner.
repair under-21 remarkv section or on the back of this brm.
23.5ite 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
constriction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
� SUBA4ITTAL INSTRUCTIONS
9.Total well depth below land surface: SS (ft-) 24a. For All Wells: Submit this, form within 30 days of completion of well
Far multiple wells list all depths if dierent(arample-3@200'and 2@100') construction to the following:
nnI
- i 0.-Static water leveh ofcasin :—''''below to �'p g J— - - --A) - DI1.7s10n of Water Resources,Information Processing Unit,
ur-lerci 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
1 Rotary above, also submit one copy of this form within 30 days of completion of well
i i.e.
Well construction method:.auger.rotary,cable,direct push,etc.} construction to the following:
Division of Water Resources,Underground Injection Control Program,
i FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gpm) Method of test: Air Blow 24c. For Water SupVIv&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: lorine Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016