GW1--04903_Well Construction - GW1_20230728

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WE L L CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I
1.Well Contractor Information:
Ch-istopher Greene ?:,4 y t f.m zr .-
FROM TO DESCRIPTION
'.‘,:l ontr.ctnr\C,..-
1 ft. ft.
2135-A I i
ft. ft.
V c:i('onnrac:or Certification Number Y7 T 3 ir-7". i7 c ^cam' -c,3 w' 'WT '. ., :
A&F WELL DRILLING, AND PUMP SERVICE INC FROM I TO DIAMETER THICKNESS 1 MATERAAI.
o 0 ft. -1 ft. -in.
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2.W ell Construction permit#: SI1sa3 -0059 FROM 1 TO I DL4MET I THICKNESS I }IATERIAL
rni;r,a• ur./.,casrtvrcticn.phenols li.e. L7C.County.State. Variance.etc.t ft. ft.
in.
3.'r'cii L.se(check well use): Pt ft. ��R� to
tt,later i;*.t t`?c�..:.. -..'�{ ,w.b:°'..ra� 3eF .V. .[w�'-4i4F2e:.e.T}�k`. -T i;g /Z I::f'-„-
Supply Well:
FROM I TO DIAMETER SLOT SIZE I THICICNESS I MATERIAL
:1_r courts: EDMunicipat/Public ft. ! ft. in. }1 !
(icotherma i Heating Cooling Supply) Residential Water Supply(single) ft. I ft. in.
77 ,,i,:sl, ,..Commercial 0Residcntial Water Supply(shared)
.zat ion FROM i TO Fv i MATERIAL EMPLACEMENT METHODS AMOUNT '
Non-Water Supply Well: ® ft. _t1�1 ft. sandmix poured
i\ionitorir.g Recovery ft. �C�1 ft.
injection Well: = f
.. _ _
t?...::te Recharge • oGroundwater Remediation
`a.u: er Storage and Recovery Salinity Banner FROM TO MATERIAL i EMPLACEMENT METHOD
"l.s:ui?er Test DStormwater Drainage ft. ft.
cxpe t:entai Technology DSubsidence Control ft. ft. i
L
r:eo:i:c�n-,a:!Closed Loop) �1Tracer _.,:. ,,..
FROM ' TO I DESCRIPTION(color.hardness,soil/rock type,train size.etc.)
7C.i,:othenna i i-leattngiCooling Return) //�� Otther(explain under#21 Remarks) ft. ft. i
4.Date Well(s)Completed:JUI IRMA/ell ID# 1 ft. j ft. I •
ft. ft.
Well i.ocation: C 1 F
!y "! �" IF
1 `,6f kl\e ft. ft. c m es.. s,�
(h aceNana rzcilit}'ID= ft. ft.(ifzpplicablc) JUL 2
Run6.
20Z3
DRIVE) i ft. ft. irl ,,rm-at`.n Prca.-Acss4m 13rii
•Ii::i.-lcdre. .City.and Zip ft. ft. �,+j'O/•SOC.3 •
'kft -fie `..A _.�, "` .,_. ray - .
.'.ZIr�.. 'r#RI�;...>rux_CY. -';.Mr.�. i- J..a.X: -wC�t.._.....y :.�.
Parcel Identification No.(PIN)
•
.....Latitude and longitude in degrees/minutes/seconds or decimal degrees:
one.at'lung is sufficient) 22.Certification:
N
.ajar:)the we1(s)$f Permanent or Temporary Signature of Certified Well Contractor Date
Br signing this form,1 hereby certi6•that the v.ell(:y was(were)constructed in accordance
.c this a repair to an existing well: DYes or gNo with 15.4,•CAC 02C.0100 nr 15A.NC1C 02C.0200 Weil Construction Standards and that a
t:.is,r;c;nari•.nil•na known well construction information and explain the nature of the copy al this record has been provided to the well owner.
-. -;marks section or on the hack of this form.
23.Site diagram or additional well details:
For Cseoprobe,'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
;::str.:coon.only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL LNSTRUCTIONS
.Total well depth below land surface: L,, 5 f (a') 24a. For Ail Wells: Submit this form within 30 days of completion of well
..;ds list a•//depths if different(example-3(4200''and 2@100') construction to the following:
i 0.Static water level below top of casing: l V ' (ft.) Division of Water Resources,Information Processing Unit.
1617 Mail Service Center,Raleigh,NC 27699-I617
:.Borehole diameter: 6 1/4 (in.)
24b. For Infection Wells: In addition to sending the form to the address in 24t:
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
•_ . cante.dire ,push.:net
Division of Water Resources,Underground Injection Control Program,
OR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
3;¢.Yield(gam) 10 aPrn
Method of test: Air Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
:3 .Disinfection type: Chlorine 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 2-22-2tIll