GW1--00827_Well Construction - GW1_20240205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
;.Well Contractor Information: 1 •
FROM TO DESCRIPTION
ft. ft.
2135-A ft. ft. '
'•\<• cwizraecor Certification Number s
Air Ws -DRILLING, AND PUMP SERVICE INC FROM 1 TO DIAMETER THICKNESS MATERIAL
o ft. QQ ft. in.
^/ /n�7{�. ..._-x-4�4't� ,.za•,.r, .r . 3s` ,t{' q,,,
1.N el:C'unstr action Permit 4: Li 231 - (w`�-- OZQO---- - FROM 3 TO- -- Dt.4,Y.E I"TIiiCXNE55 I MATERIAL -
.... .,.,.:e:rd1 rw:siruction permits(i.e.UIC.County.State. Variance.etc.) ft. ft. in. I
I
?.fit:eli I se(check well use): ft. ft. in.
!ISVA `� ---. _;„te a Exa z;".aver Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS 1 MATERIAL
:Agr.:u:::rai OMunicipal/Public ft. in.
i ft. I
(ieotrierntal;Heating Cooling Supply) Residential Water Supply(single) ft. I ft. in.
I
_ i
...h:..ar.a:Commercial C
.,.,..u."a Residential Water Supply(shared) �. ,, '��"' 3:;` ' '�;,�r,�� -:. ge i� 4 .,: ..,
igat:on FROM TO 1 MATERIAL EMPLACEMENT METHOD&AMOUNT_
an-V arer Supply Well: 0 ft. ft. '
l sandmix poured
\h.rdtor:ng 0Recovery ft. .ft. I .
::ection ll'eli:
' ft. ft. ,
er Rechargt • DGroundwater Remediation
tar Storage and Recovery QSalinity Barrier FROM I To MATERIAL , EMPLACEMENT METHOD
n fer Test DStormwater Drainage ft. ft.
i
i:?xperimentai Technology DSubsidence Control ft. ft.
,..et. ,:;Closed Loop) E3 Tracer - :g ; €z:,
�., gReturn) (explain "21 Remarks) _FROM TO DESCRIPTION(color.hardness.soil/rock type.grain size.etc.t •
;.feothcrnia:i Heating/Cooling Other ex lain under g ft. ft.
KK 11,,,ee�� ft. ft.
..p \\'e1i(s)Completed: f-pJ3-NL�(� Well DM _ _ ,
\,eiii.ocaion: ft. ft. 1. - V1. ,� )
—�' '1 I ,v'fi....t /
1 1'i 1M. - - - -- ft. ft.
- . t .c:\'ar.:e Facility iD=(if applicable)
ft. ft. i CCI �j L�L.A_
III
Ntrichins ck)Uow Rd ft. 1 ft. ti1f3r:i=r3.i?n UISa
ldd:•-. .C:• and Zip ft ft LT.-a+ 'ti.+� •
Fu-I-her olyd 18�9(3g9 . . :Ate _& { i 4..i—: _
Parcel Identification No.(PIN)
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
'•c:...,:d.one lat long is sufficient)
22.Certification:
N
W G � 4"" I-e23 c)O y
:.a(are)the wells)"Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby certifi,Iliac the wellO was(were)non.untcted in ac•c•ordmcr
-.:s this a repair to an existing well: DYes or xDNo • with 15.4.VC.4C 02C.0100 or 15.4.VCAC 02C.0200 Well Construction Standard.,and that t.
i..,:.car parr,r)ii gut known well construction information and explain the nature of the copy of this record has been provided to the well owner.
... .....•,, 2:,t.mucks section or on the hack of this form.
23.Site diagram or additional well details:
. nr 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
.:::.etion.only i G<< i is needed. Indicate TOTAL NUMBER of wells construction details.':You may also attach additional pages if necessary.
,......t.:• One,
ll�� SUBMITTAL INSTRUCTIONS
-otal well depth below land surface: WO 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
:. . .r:.s L•5:all depths if different(example-3(g2000te�and 2@1001 construction to the following: j
.•:.Static water level below top of casing`_ .J, (ft.) _ __Division of Water Resources Information Processing unit,__ _
' ,,ana `nisi ng•use"_- 1617 Mail Service Center,Raleigh,NC 27699-1617 _
::.Borehole diameter: 6 114 (in.) •
24b.For Infection Wells: In addition to sending the form to the address in 24i:
Rotary above, also submit one copy of this form within 30 days of completion of well
:.\fell construction method:
..... direct push.etc.)
construction to the following:
Division of Water Resources,Underground Injection Control Program.
=.)R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
?::.Yield(rpm) Method of test: Air Blow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
h.Disinfection type: brine Amount: 34) completion of well construction to the county health department of the county
where constructed.
.. - ••-. North Carolina Department of Environmental Quality-Division of Water Resources Revised 22-22-2n I r,