GW1--04672_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: "
1.Well Contractor Information: '
1
Christopher Greene 4kv,Vi.L'kxlu3?l .h -0.1tf '-; ::iMaTiKe. m.:
)fell Contractor lame FROM TO DESCRIPTION
ft. ft. i .
2135-A
ft. ft. I
\C Well Contractor Certification Number 15 UTE ,A -,(Sf *IIS R -;. -Yp „. 3..
A&F WELL DRILLING, AND PUMP SERVICE INC FROM 1 TO DIAMETER THICKNESS MATERIAL
ft. . 'in.
m,
.'tpany Name kill® r� ^ 40 ft
2.Well Construction Permit m: FROM TO DIAMETER I MATERLAL
.q all applicable well construction permits(i.e. IC.County.State, Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft in.
i Water Supply Well: l.,D,:SCR EN;.}a:::F 'e = ..Si'L'Y' :5 4i.s _- I ram£: W.: z.;is
_FROM TO DIAMETER SLOT SIZE THICKNESS Xi MATERIAL
0Agr•icultural 0Municipal/Public ft. ft. in
GcothcrmaI(Heating Cooling Supply) EarResidential Water Supply(single) ft. ft. in. j
'industrial Commercial
DResidential Water Supply(shared) .Ati,o.Rou l-b r 7, .y , n r Y. . stir ': ,tug 4
- (Irrig*ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'1
j Non-Water Supply Well: 0 ft. 010 ft* sandmix poured
DMonitoring DRecovcry ft. ft.
Injection Well:
ft. ft.
•Aquifer Recharge ..0 Groundwater Remediation
s Aquifer Storaec and Recovery pp��Salini BarrierAtIANtiglialM `"
E...1 ty FROM TO MATERIAL • EMPLACEMENT METHOD
Aquifer Test ` DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop)8 Tracer
.,2it:DRIX+LING strtactiiiildsta bhYll stieeis il` ..,, :,<;
(�Creothennal Heating COOhn Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Ems} ( g/ g Other(explain under#21 Remarks) ft. ft.
4.Date Wells)Completed: `ea'c� .�grell iD# ft. ft.
Sa.Well Loca'o ft. ft. ,tT" ` _q�ll
s ka chic 14J1°�_�, i..- a
� ft. ft. I�
Facilin,'O.tnerName ft. ft. JULFacility ID#(if applicable) J J ? 12023 I
1 y 64 ft. ft.
r�I Add css.City.and Zip ft. ft
IL . cij rd 1(el LI.3 LI.(p Dwoje6G------:-6,u,d'i.
(own: Parcel Identification No.(PIN)
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
it well field.one iat'long is sufficient) 22.Certification:
N W
5.is(are)the well(s);k` iPermanent or Temporary Signature of Certified Well Contractor Date
Br signing this form,1 hereby certih'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or IlifNo with/5.4 NC4C 02C.0100 or I5A NC IC 02C.0200 Well Construction Standards and that a
it:hi.,is a repair,;i11 out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
rrrair under =2!remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:lane
SUBMITTAL LNSTRUCTIONS
Q�9.Total well depth below land surface: 5' (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
r4.r malt;ple we&list all depths if different(example-3@200'and 2@/00')
construction to the following.:
__AU.Static_K_ater_Ievel-below-top-of-casing:- =--- U- - -- ------(ft) - Division ofWaier ResourcesInfocmafion-Processing Unit.
;:er!c.r!is:bore casing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (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
12.Well construction method: construction to the following:
i.e.:user.rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
' 13a.yield(gpm) 5 9P n-t Method of test: Air Blow 24c. For Water Supply&Infection Wells: In addition to sending the'form to
Chlorine
13b.Disinfection type: Amount:, 3^ ,/�,� the address(es) above, also submit one copy of this form within 30 days of
a f[Jf]r completion of well construction to the county health department of the county
V where constructed.
• c 11t-: North Carolina Department of Environmental Quality-Division of Water Resources
Revised__2-27
_016