GW1--08015_Well Construction - GW1_20231214

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
. V.ell Con:ractor Information:
i
.-'stobher Greene' ;.,L .. -,.. Y ' . s=:: .. =�::,*;:, . . . '
\::n: FROM TO DESCRIPTION
0 ft. 1 ft. 1
5 A. t,/ ft. ' . ft.
t
•
1
...- c':at;,caaor.Number .—
- = •' E DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER} TRIMNESS M.ATERIAL '
\ , ft. O, ft. 1 ,l in.
_. _.:Construction Permit n: $4 033 i FROM TO I DIAME '. THICKNESS_ MATERIAL
../1 L y .. ft. ft. in. I
:; •.r..:r,,:sr ec tiara permits(i.e. IC.i Dunn i'State, ariance.'et<t1 i -
ell s (check well use):
ft, fa I in. 1
c: ppi� Well: .x.7-Yt.z4Z::'.
FROM TO DIAMETER SLOT SiZE THICi NTSS I MATERIAL
OMunicipal/Public ft. i ft. in.
-. .,,Heating Cooling Supply) arResidential Water Supply(single) ft. I ft. in.
.. ....,, ,,crcial - DResidential Water Supply(shared) ogoosa , .V ,E-F- , ggigans, s
.. .E:tio.n FROM i TO : MATERIAL EMPLACEMENT METHOD&.AMOUNT
r Supply Well: i -
D ft. ft. sandmix I poured
" +`::'_ Recovery ft. ft.
: .~ion Well:
ft. ft.
Ret 1arOe • DGroundwater Remediation '
-'4=-. ire_..
•..`.r S:::'age and Recovery Salinity Barrier FROM TO 1 MATERIAL 1 EMPLACEMENT METHOD
DStormwater Drainage ft. ft.
L
._nra;Technology DSubsidenceControl ft. ft. l .
•
..
--. a. y Closed Loop) DTracer -. I .. _sir,....
. i eating;Cooling Return)^^..�
!
3Other(explain under 721 Remarks) FROM TO DESCRWI ON(eolor.hardness soil/rock type.grain size•erc.i
-..a;.°3.'eii(s)Completed:I42`�`c2(�J, Well ID# ft. ft,YI
Location:
ft. ft.
,11?s�uu"r"Div` NippeU%al -
�,� Facility ID:(if applicable) i ft. ft. :11:...-,:;1,.. :' ;fin a -..;",.,.•_ ,
•
ft. ! ft. •'-1 VI �i..U.:i �: l..tS.
nd Zip ft. I ft.
_Nlther f bRd, /o36'f 5 7 , ; * ...._ - :: .
Parcel Identification No.(PIN)
.-_atitude and longitude in degrees/minutes/seconds or decimal degrees:
:at long is sufficient) 22.Certification:
•
N W � �/ /2`7-c2c
.^e wed(s)EPermanent or EtTemporary Signature of Certified Well Contactor Date
Br signing this form. 1 hereby certify that the welltst was(were)constnwted in at•cord n::
-.: :his a repair to an existing well: °Yes or nifNo with 15.4.t'C.4C 02C.0100 or 15.4.VC.4C 02C.0200 Well Construction Standards and t;::u c
. s;:;r•?Ili-nit known we/I construction information and explain the nature of the copy gtthic record has been provided to the well owner.
-. -marks section or on the hack of this form.
23.Site diagram or additional well details:
C er,irrabe/t�PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or .ye::
:::�': ii�i-'I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
, . SUBMITTAL INSTRUCTIONS
•. . .,a:well depth below land surface: to (ft.) 24a. For All Wells: Submit this' form within 30 days of completion of well
.. •, .,i•sr all depths if different(ecample-3(ti?00•and?@100"1 construction to the following:
J— — -- — i
�:a=;v,ater level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit.
.. casing.use'--•• 1617 Mail Service Center,Raleigh,NC 27699-1617
. -e diameter: 6 1/4 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 2-::
Rotary above, also submit one copy of this form within 30 days of completion of we:
.-..4 c::construction method: construction to the following:
.-_...erect DUSK.etc.)
Division of Water Resources,Underground Injection Control Program.
TER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
Method of test: r Blow 24c.For Water Supply&Iniectionl Wells: In addition to sending the form :c
. .fild'e ;;am) 5 pmAi
Q� the address(es) above, also submit one copy of this form within 30 days of
.,.D:sinfec.or.type: brine Amount: . /4� AJ completion of well construction to the county health department of the co;::::
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2')i r.