GW1--06677_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Christopher Greene at:V TA; ll s.t: a i :-. ,S,�. :. Q.Ay ., a . -
FROM TO DESCRIPTION
1�a Contractor Name ft• ft. 1
2135-A '
ft ft. iii
\i"R ell Contractor Certification Number
A&F"WELL DRILLING, AND PUMP SERVICE INC FROM I To DIAMETER 'THICKNESS MATERIAL
p o ft 15 ft. .in. I
L"nmpany Name y,� x� „
Wa3-0 33 `a`.I ANNEI O Stilt.ti VG( Lclssed'auGi . ..; ...._
2.Well Construction Permit#: FROM• TO DiAMETLr£t 1 THICKNESS 1 MATERIAL
I.:ad applicable well construction permits(i.e.LlC.County.State. Variance.etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
y hater Supply Well: i'17'SCREE�h ,, :;a f. .t._. A..' .s " 'Z= ..e ;` =7
FROM TO DIAMETER SLOT SiZE THICKNESS I MATERIAL
.\gricultural OMunicipal/Public ft. ft. in.
GGcothcrmal(Heating•Cooling Supply) Residential Water Supply(single) i
PPY) PPY( g ) ft. ft. m 1
, ..tindustrial Commercial DIResidential Water Supply(shared) si$ra1211I:'1 .. .- '" .ri?;_ :- Sn :.`r-u .„ >;i
t LIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT i
Non-Water Supply Well: C 0 ft. fJd1,o ft' sandmix I poured
J\•tonitoring Recovery ft. ft. ,
I Injection Well: •
ft. ft. •
DAqui terRecharge • DGroundwater Remediation
•E 19MMIGiaeG• ikjAtr(Ir tplic3TiXe « •KV r 4. . .,
o.quiter Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ` DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft. 1
DGeothcrmal(Closed Loop) Tracer (A T GL' tae1itailttioiiiiff eels£ sss;✓y";)2 ,..: `,.. .
Cieothcnnal(Heating Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
�i in Other(explain under i 21 Remarks) ft. ft.
4.Date Well(s)Completed:Iii.1 �202 ell ID# ft. ft. i
5a.Well Location: J ft. ft. A:1h T
•
ft. ft.
�L' Rkarq C'hrt ' 1e cec � . Fnr s
rccilnin Owner Name ,�yy� pp��,.� Facility IDe(if applicable) ft. ft. QCT I ' 2n
1 q I El I-Ibt Rc ext ft. ft.
i' sircl Address.Ci; ,and Zip ft• ft. IINCt i;,-•r^n..'! .,-s n I ti
ru nd (4 5 (00 4 23,-It' tAitg.S eels,:.: M:ro t.. ._c .n.X..:k. . trt r rya ,. _. •
i
arn:. Parcel Identification No.(PIN) I
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
1 w ell ticld.one lat long is sufficient) 22.Certification: 5
0
N
23
6.is(are)the wells) iPermanent or ®(Temporary Signature of Certified Well Contactor Date
By signing this form.I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or t�No with 15.4 A C.4C 02C.0100 or 15.4 NC.4C 02C.0200 Well Construction Standards and that a
I:this is a repair.lill out known well construction information and explain the stature of the copy of this record has been provided to'the well owner.
n itair mules tt 21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
X.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,only i OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: oneSUBMITTAL INSTRUCTIONS
0
9.Total well depth below land surface: 05 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple:tells list all depths if d ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: HO (ft.) Division of Water Resources Information_Processing-Unit, =_--
,..,-5•i ci i,,d,at'e(asing,use '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
'.I.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: '
);.e.a).er.rotor).cable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
I FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
! i 3a.Yield(gpm) IO sp YI 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
13b.Disinfection type: Chlorine Amount: 30) 0h completion of well construction to the county health department of the county
where constructed.
..r.:n -: North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016