GW1--05572_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1
:.11'ell Contractor Information: 1
Christopher Greene z :
FROM TO DESCRIPTION
%I% .)mains\s
ft. ft.
2135-A
ft. ft.
('n^t-e..or Certification Number . . �- - - - ..y r. r, .
.A&F WELL DRILLING, AND PUMP SERVICE INC FROM { /TO DIAMETER '[THICKNESS (-MATERIAL
0 0 ft. " i 5' ft. �in. 1 ,
....�.n y\'Lime i
s.11eI:C utstructfnn Permit 3_� COB FROM TO i DIAMET fy THICKNESS 1 MATERIAL
•• d•ie:01 ••unxn•uction permits(i.e.L'IC County.State.Variance.etc) - ft. ft. in. I _
•
n eil 1_se(check well use): ft. ft. in.
e: Supply Well: FROM I TO DIAMETER .SLOT SIZE I THICKNESS I MATERIAL
:,:n:l.;ra 0Municipal/Pubiic ft. I ft. in.
(;comerrnal t Hcating-Cooling Supply) Residential Water Supply(single) ft. ft. in. 1
:.:>a. .C,.,t.....c,a: Residential Water Supply(shared) err .(- •€.r w :, :
i••:•41ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
Non-Water Supply Well: Ct. 1 r tt. ��dmix poured
lionitor:ng Recovery ft. �d ft.
'injection Well:
t. ft.
• •,.•• Recharge , oGroundwater Remediation
iL.•1.:,:ter Storage and Recovery DSallnity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
.:`:liter Test EtStormwater Drainage ft. ft. '
x? r•mentai Technology D Subsidence Control ft. ft.
•..o: cT:a;:Closed Loop) DTracer a"VrageflagiMell- •,� -�+' .;=-
FROM TO I DESCRIPTION(color.hardness.soil/rock type.grain sue,ere.) •
_ i.e hen:ta:;Heating/Cooling Return) DOther(explain under#21 Remarks) ft. ft.
Date Well(s)Completed 3. ell[D� ft. ft. "'- -...D
Well Location:
ft. ft.
- fir..Well
[',,aurto -- _ ft. ft. AUG 2 '2023
:.:;t:. • cr r e �Facci_li y ID (if applicable) ft. ft. •
l rp� l,�� Pr c•.. i !!Ct
CI 10 EI I 1 Rd R �I on ft. ft. DWO12.04)
-� ;.;'dye:..Cl: .and Zip ft. ft.
AU-Lfrer-f\Or011 attsgEEVggtre.V.A*Z'Ifrett.g.V.it:it '... .EL.V .Zi-:'-Wg.r.t<:f-Y .•:- i
Parcel Identification No.(PIN)
5::.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•-:-s:ii!e:d.<+ne fat long is sufficient)
22.Certification: 1N
W 644;"....."4:64. I'a5-oXV3
:,.:s(a re)the w•ell(s) Permanent or Temporary'
Signature of Certified Well Contactor , Date
Br signing this form, i hereby cernfv that the well(s)wets(were)constructed in accordance
-.:s this a repair to an existing well: DYes or SiNo with 15.4.'CAC 02C.0100 or 15.4 NC4...02C.0200 Well Construction Standards<uui ilia:
•:;ta i;a rt••racr.till nut known well construction information and explain the nature of the copy of this record has been provided to cite well owner.
-marks section Lion or on the hack of this form.
23.Site diagram or additional well details:
or 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
:uns:r.:ction.only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
"`'d: •=one SUBMITTAL INSTRUCTIONS
:. .ctai well depth below land surface: 05 i (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
:::,:.Pis:•.ra iisr all depths ifdltlerent(example-3(0400'end 2@100') construction to the following: •
• .t:.Static water level below top of casing: 40' (ft.) Division of Water Resources,Information Processing Unit.
1617 Mail Service Center.Raleigh,NC 27699-1617
.:.Borehole diameter: 6 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in Na
Rotary above, also submit one copy of this form within 30 days of completion of well
.2.V ell construction method: construction to the following:
_ . ... ........ ';Cr..,.t e.direct push.etc.) •
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLYWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
::.. .Yield(gpm) 10 S Method of test: Air Blow 24c.For Water Supply&Iniecti n'Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
:�i).Disinfectionisinfection type: Chlorine Amount: ®� completion of well construction to the county health department of the coun:
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources' i Revised 2-22?nit,