GW1--04792_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: I ,
Christopher Greene `14:.WATERZONEs._ 4 ,,, #< M . s.-
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2135-A '
ft. ft.
NC Well Contractor Certification Number :1Si;0U.TER CASING::(for mrilu=cased Wells)`.ORJeU' R((if`ap'li ble) `'=
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. I . v ft. s,in.
Company Name � /, 16:.INNER•CASING ORaTUBI NGG(neathermal(close -lo dop) ;pZ i`:- .`.
2. (Well Construction Permit#: I 1 5 4- 40 FROM TO DIAMETER- THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State. Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
,,17:'SCREEN �_: . h _: ., .* ' �.xlY>. ,
Water Supply Well• FROM _ TO - DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural OMunicipal/Public ft. ft. in:.
Geothermal(Heating/Cooling Supply) Iglitesidential Water Supply(single) fit, ft. in.
lndustriaVCommercial °Residential Water Supply(shared) _`18.GOUT `fir.., .-
Irrigation FROM TO' MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.0 fit. sandmix poured
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharee Groundwater Remediation
14:SANDIGRAVEL PACK(if appbcab1e t , _'a .. a, . u. _,_::
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test
1 �Stotmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
-
Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) 20:-DR[LUNG1:OG4iota``ch';addidaal'sheets;Wnecessa }; ,, ..1.; ,..,Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
. /- rn ft. ft.
4.Date Well(s)Completed:lo-f 9-07 Well ID# ft. ft. _��,,,1 ,�
Sa.Well Location: ft. ft. 1 `� 1. V L D
o
i 221 s MEI le Norm Marers
ft. ft. JUl t 2023
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. hreruie+.raiifla i'Ci;C .,g 14.0.
tat Juani-ta s+rett rcurvlelf Acres o
Physical Address,City,and Zip I Of
ft. ft.
Cleveland .2i:xEEM E,
ARss . ,_. .._ t:.
County Parcel Identification No.(PIN)
•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:
N WG �y 6-22-2023
6.Is(are)the well(s)'Permanent or Temporary Signature of Certified Well Contractor Date
By signing this forth,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the stature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
3.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,onl 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:'°Q(� construction details. You may also attach additional pages if necessary.
• SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: Oki (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@i00') construction to the following: ,-.
._ _ 10.Static level below top of casing:_ "t'C/ _(fit.)-__ -—Division ofWater-Resources;Information-Processing Unit,- - ---- ._}
If water level is above 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.auger,rotary,cable,direct push,etc.) .f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
30 13a.Yield(gpm) apm Method of test: Air Blow 24c. For Water Supply&Injection Wells: In addition to sending the form to
�l �^ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine the
3.1 Q0 completion of well construction to the county health department of the county
_(� where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016