GW1--05573_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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Well Contractor Information: ,
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-:.
Christopher Greene
FROM TO DESCRIPTION
'.'..... L.-.r!;:,,nor Name .
ft. Ift. 1 1
2135-A I ,
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A&F WELL DRILLING, AND PUMP SERVICE INC FROM ' TO DIAMETER; THICKNESS , MATERIAL
lir, I
:i.NN 211 Conmstruction Permit#: Skil2t)3 ** o@a3 FROM TO I DIAMET ' THICKNESS i MATERIAL ,
ft. - I
.:.:.:arei:;•,;1•Fe weii,,ntstrtiction permits!i.e. LK.Canna..State.Variance.etc.) • ft. in. .
•
3.sr‘ell I se(check well use): ft. ft. in. '
‘,-,vei•Supply Well:
FROM I TO DIAMETER; SLOT SIZE THICKNESS I MATERIAL '
DMunicipaVPublic ft. I ft. in. •
..(;cotnemtal;Heating Cooling Supply) Fif Residential Water Supply(single) 1
ft. ft. in.
i
' •.:',..i:sinzi.C omiiicrcial 0 Residential Water Supply(shared)
......
:.;•:.;:tation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
t:11-Water Supply Well: 0 ft. 1:00 ft. sandmix I poured
Nonitor:n2 Recovery ft. ft. 1 •
injection Well:
. .. :
Recharge • EiGroundwater Remediation
VitiaMetkilalgritigaitnatIgiMWAMI.: :::. :
.- t.A..:::::Cr Storage and Recovery Salinity Barrier FROM. TO MATERIAL EMPLACEMENT METHOD •
' C-‘ i..r Test DStormwater Drainage ft. ft.
Expeninental Technology EsSubsidence Control ft. ft. ',
nc :!, .:(Closed Loop) DTracer
FROM TO DESCRIPTION(color,hardness,soil/rocktype,grain SIM.CIC.I
Lothenna;i Heating/Cooling Return) riOther(explain under#21 Remarks) ft. ft.
-.Date Well(s)Completed:8-15-aDa3Well ID# ft. ft. I '
r-. r•-•r..., .: --,
L.11.---i Vti i
, Weli location: ft. ft. r‘C
ft. ft.
- Boon Chns4Dpher Boone, .
• . _AU-G 52023
-.•;)wnor Fame Facility ID#(if applicable) ft. ft.
I ,Intritinalicii i'fre.-twiwerg UM(
lqi E -Ilt P01 ect. RtiherfercHon ft. ft.
. DWCV?:ROC:4
'.:..:,....:1 A,tidres•:.(ity.and Zip ft. ft. ,
'RalterfOrd 1(0,5630 Lfa
Parcel Identification No.(PIN)
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
, r•'‘‘.:;!i'IL:Iii.one:at long is sufficient) 22.Certification:
N W ....6e.;•-•-•:,494:-...c••••"9. . 8-fr1-c7Q3
f
Signature of Certified Well Contractor Date i.:s(are)the well(s) Permanent or Temporaryo
• By signing this form,1 hereby certt6 that the well(%)was(were)constructed in uccoreiancc
-.7s this a repair to an existing well: DYes or ENo with 15.4 NC.4C 02C.0100 or 15.9,VC.4C 02C.0200 Well Construction Standard,-and that a
• I.•. .;,,Tair.till mt known well construction information and explain the nature of the copy of this record has been provided to the' well owner.
•,:•• ,'es •t-rnarks section Or on the hack of this.form.
23.Site diagram or additional well details:
•••.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 details. You may also attach additional pages if necessary.
,:onstr,:ction.only I GW-1 is needed. Indicate TOTAL NUMBER of wells
::...- cti.: .one-
SUBMITTAL INSTRUCTIONS
Total well depth below land surface: cgO5 I
(ft-) 24a. For All Wells: Submit this:form within 30 days of completion of well
•....,::,....,/,,,,:,v;is lest ail depths ildifferent(example-34200 and 2Q1001 construction to the following:
.Static water level below topof casing: 30 (ft.) ______
Division of Water Resources,Information Processing Unit.
.. .;•,.. .:-.e Lv„hove easing.use"'-.. 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 24e
Rotary above, also submit one copy of this form within 30 days of completion of well
7 2.Well construction method: construction to the following:
• „:.,.::.rotor...canto.direct push.etc.;
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
:3a.Yield(gpm) ID 3pm 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 b.Disinfection type: Chlorine Amount: 36 completion of well construction to the county health department of the county
where constructed.
*. .•:.:Av.: North Carolina Department of Environmental Quality-Division of Water Resources I ' Revised 2-22-201 r,
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