GW1--00780_Well Construction - GW1_20240131

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
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:.Well Contractor Information: I 1
Christopher Greene ,. y -, - t x
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FROM • TO DESCRIPTION
.s_. t nr.:ru;:nr Na ft. ft.
2135-A ft..I ft. I i
'A Con(raaar Certification Number
.;&F- WELL DRILLING, AND PUMP SERVICE INC FROM f To DIAMETER I THICKNESS MATERI.>t.
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.. 2.s'>ei C'onstructiOn Permit#:-Wd3.2 06 075 J-'FROM - TO-- '-'-� DIAME THICKNESS I MATERIAL -
... .,.,.:;u14/constrry nor•permits 0.e.L'1C.C'nou n State. Variance.etc.)
ft• fL in.
f;. •= \'.� oil I se(check well use): ft. in.
:sa;cr Soppy ��'el! ,r4,, m - . ," "` .`. -2117
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• FROM I TO DIAMETER SLOT SIZE . THICKNESS i MATERIAL
:.• :::.r,:i
••l OMunicipal/Public ft. I ft. in. f
,:cot:erra:;Heating Cooling Supply) eiResidential Water Supply(single) ft• i ft. in.;
.. i.:striz:CnmmcrvialResidential Water Supply(shared) ..r � r - : -
7.•;•.-t_a•• n FROM i TO I MATERIAL EMPLACEMENT METHOD&AMOUNT_
N.un-Vrater Supply Well: 0 ft. 6?0 ft' I sandmix , poured
,\lontiortnt DRecovery ft. ft.
lr.fection Well: ft. ft. '
.for Recharge •: (Groundwater Remediation
. r t� Storage and Recovery ElSalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD^
...11;i;er Test 0Stormwater Drainage ft. ft.
Lxperitnenral Technology Subsidence Control ft. ft.
looi. (Closed Loop) EsTracer :*:- : r.;
t icothermai t Heating/Cooling Return) [Other(explain under#21 Remarks) FRo�t TO DESCRIPTION(color,hardness soiUroektvpe grain size.etc.(' •
h� ft. ft. i
..Date Well(s)Completed:I'$'Jua?y- Well ID# ft. ft. F,
;';ei:. ft. ft. n'>� .,' P.:- `,_,.i
t.oca;ion: n r, . 1..,,ga.."
�__t_ Ca_•__ ft. ft. 3 t 2074 —
..c '\ar,.c Facility ID4(if applicable) ft. ft,
I4•I�(o 1 Camp Nei() � Unl� '•VUIS ft. ft, •.� a . :,...,;?,:::g i)P:.'a
✓'75s•�l�1.`��i y
R. \:i... and Zip �A—/�JQ/^{rr�ry( ft, ft. y
--" f� 1d I WW4.J053 �'s . ' .f"•'.z'a':u"`iaY`Lk..' 7a£7r•'o =i sV.O.'- max° .ye:g0g-..' k`..."x-�'..gl)g.t„L.
// Parcel Identification No.(PIN)
....Lztitudc and longitude in degrees/minutes/seconds or decimal degrees:
.‘:!ti:'(1.ore at long is sufficient) 22.Certification:
Vy644":"."..../11. 4.49 ,
n.afar^)the vvell(s) Permanent or Temporary Signature of Certified Well Contactor f tate
Br signing this form.I hereby certifi•that the well(.)was(were)constructed in acs-ordcm;r
".:s this a repair to an existing well: f Yes or rffiNo with 15.4.VC.4C 02C.0100 or 15.4.VC.4C 02C.020a Well Construction Standards and that a
r en,;:r.rill ma known well construction information and explain the nature of the copy of this record has.been provided to the'weli owner.
... -• .:•mums section or on the hack of dais 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 w'e:i
.:.a:::.eiio:;.only GW l is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
iod:•:one
3a5 SUBMITTAL INSTRUCTIONS
?. :'ctal well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
... . e:airs list all depths if different(example-3(d400'and 2@100') construction to the following: 'j
r/ -� /
Static water level below top of casing: GO' (ft.) Division of Water Resources,Information Processing Unit.
—. -r:,)i':;,�(ag,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 24::
V.ell above, also submit one copy of this form within 30 days of completion of well
construction method: construction to the following:
_ ..ratan eahie,durec:push.etc.)
Division of Water Resources,Underground Injection Control Program.
;)R V.ATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
', Yield(rpm) ID op 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
7:4.3.Disinfection type:
t'Ftlorine Amount: completion of well construction to the county health department of the county
where constructed. {I
:• ... • ,• : North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-201 t,