GW1-2023-02929_Well Construction - GW1_20230420

'WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ell Contractor Information:
Christopher Greene
Contractor Nante
FROM TO ~DESCRIPTION
,i cti
2135-A
ell Contractor Certification Number a
A&t- WELL DRILLING, AND PUMP SERVICE INC r•R3M TO DIAMETER THICKNESS MATERIAL !
ft. ft. .n
Xame...i.
2,\\ell Construction Permit rut• FROM I TO I DIAMETER, THICKNESS I t1LATERLAL
:i'gnniir•dhlr ir['hcorisnvuction permits(i.e. UiC.Count)•.State. Variance.etc.; rl: L ft.
3.Well Use(check well use): ft. Ct. in.
Water Supply Well: ?
- FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
D.lgriruhural 13MunicipaVPublic
:36co(hcmtal(Heating:"Cooling Supply) ffResidential Water Supply(single) ft. rt. in.
Jinclustriai Commercial 13Residcntial Water Supply(shared) ;;.2&t U-I, _ -.••t.t.,• ;_ -Y, • r,. • `.
i. t:Irrigation FROM TO W MATERI.aL EMPLACEMENT METHOD&AMOUNT
Non-\Pater Supply Well: ft. /{� ft. sandmix poured
\lonitoring 13Rccovcry ft. �G! ft.
i Injection Well:
toAyuiti:r Recharge ®Groundwater Remediation
� �:;14r.S#�'13LGR�i�'�I" f K. ".,. • ,�,���-max,�,����<,n•�.�F"`.>;., _4 .�: �_:;.
Lt.-\quitcr Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
to Aquifer Test - 13-Stormwater Drainage
MEsperimental Technology Subsidence Control
JGeothermal(Closed Loop) MTracer '=2D°D1tIII iYr ddi8otiitl l»etx .:}_.. .'r.
FRONT TO DESCRIPTION(color,hardness,soiltrock tv e, rain size,etc.)
' Cieothemtal(lieating/Cooling Return) Other(explain under R21 Remarks) ft. ft.
* (;ate Well(s)Completed:L 02 Well ID# ft. ft.
ia.Well Location:
Tv!! 'DEAN 40UM151ccd rt. fL 1
Fa:cil�"ik-A)w ner Name I, J�pp..,,�� Facility ID`-.(ifapplicable)'l ft. ft.
.an TI111��55�r1e� �� 7�- ft. ft. irliG::i:
ical Addre, . .ity.and Zip Ct. ft. 'c..•r~:;�;`
mr. Parccl Identification No.(PIN)
�h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fwrll field,one laclone is sufficient) 22.Certification:
N W � 4-12-24D23
6.Is(are)the well(s)IgPermanent or 13Temporary (Signature of Certified Well Contractor Date
Bt'signing this l'ornh,I herehv c•erti6,that the vrell(,$)was(were)constructed in accordance,
7.is this a repair to an existing well: [3Yes or J6No with 15.4 A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and thal.0
:hi.is a repair.T77 oat kno,vn well coirsiruction information and explain the nature ofthe cons'githis record has been provided to the iaell owner.
rcmarks section a•on the hack of this iorm.
23.Site diagram or additional well details:
X.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,onh•1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
-one SUBMITTAL INSTRUCTIONS
I
y.Total-well depth below land surface: (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
•r n::d;rrir••wc lis list all depths iidi/ferent(example-3@ 20�0'and 3C100') construction to the following:
0.Static water level below top of casing: - TO' __ (ft.)- Division of-Water Resources,-Information Processing Unit, - -a:tTX1 ei;s above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
;.Borehole diameter: 6 1/4 (in.)
24b.For Iniection Wells: In addition to sendint,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: constructiovo the following:
i.e.auger.rotary.cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
i FOR\N'A•rER SUPPLY WELLS ONZY: 1636 Mail Service Center,Raleigh,NC 27699-1636
:a.Yield(gpm) 2.0 Q Orn Method of test: Air Blow 24c.For Water SuaDiv&Iniection W'elis: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
i.;b.Disinfection type: Chlorine Amount: o completion of well construction to the county health department of the county
where constructed.
r.::(111'-: North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2010