GW1--01436_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD (GW 1) For Internal lise Only: 'l
=—
..`v'.ell Contractor Information: ' •
I
.,..-'stoner Greene - 1.f zw:_ ,. _ ._1. .: :,-.. '
-..:.:;:, \�: FROM i TO DESCRIPTION
,SO-A ft. 1 ft.
• . c'..•,.::ctorC c:iticarian Number ft.1 ft.
X'= \ ELL DRILLING, AND PUMP SERVICE INC FROM TO �V�DiAMETER THICKNESS MATERIAL
ft ft. :in
.i4Y5�l-:�.
2.1,ell Construction Permit Ai: SlAi 18-- one7 FROM TO DWME . THICK-NESS.v rMATERIAL
..,••i;..rrli ruastruction permits 1Le..L'IC,County.State. Variance.etc.) ft. ft. in. i
.. :eii i se(check well use): ft. ft. • in.
�y altPublic •Munici FROM TO DIAMETER-' SLOT SIZE THICKNESS Y MATERIAL
.,... Ld' P ft. ft. in. I I
:•,..�....,`;Heating Cooling Supply) LerResidential,Water Supply(single) i i
ft. 1 ft. in. I
• ! DResidentiai Water Supply(shared) Aigissiner l
...�:.., .c. �l. .....l'rCia. ...7.4,-- e-''st .,� � t-wYSr---'`,arc. .
.,tom-� :�� S- y
--:`ation FROM I TO 1, MATERIAL EMPLACEMENT METHOD&AMOUNT
`'+^.-V,are.r Supply Well: 0 ft.. ft. �ndmix poured
.-.::or: Recovery ft. Idle) ft.
. .:ion W ell:
ft, ft.
:A..:::;c; Recharge 4 DGroundwater Remediation •_
�...-t.::::'.r :ora Ee and Recovery DISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
i;o.r'-•: DStormwater Drainage ft. ft.
:'''^.:':•"e:.toi Technology DSubsidence Control ft. ft. I
,. ,..,..:Closed Loop) 13Tracer :.
tl_`any I•• ) FROM TO DESCRIPTION(color.hardness,sorWrrock type.Brain size,etc.;
_,,_ .. HeatingiCooling Return) ee��[Other(explain under#21 Remarks ft. + ft, I 1
-.;`)a;e Weli(s)Completed:2 q 20G14 Well ID# ft. f ft.
,,.l.ocation: ft. fr. l T r L.>? Zing ram?
James L& T , I _ ft. ft. Aen 6
�.p�,� V- Facility ID#(if applicable) ft. ft.
Lee .. Forest ' I ft. I ft. infoi'ii.iien ;:roi&v":ya,t.10
ic:- and Zia Oei
ft, ft, s•�'aL}tuv
Ku. iercrd., (63061( r
Parcel Identification No.(PIN)
I:.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.s:: ::cci.:,rc long is sufficient) 22.Certification: ,
.9, ago f w 600;:-:"."4............ .
.' ,ar;)the weLt(s)dPermanent or DTemporary Signature of Certified Well Conactor Date
B:•signing this form.I hereby certifi•that the well(s)was(were)constructed in accord:oh:
-.:s:his a repair to an existing well: Dyes or i o with I SA.`CAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standards and tint w
,. .. ..,rill•rut known well construction information and explain the nature of the copy 41'this record has been provided to the well owner.
... -. -:•markc,section or on the hack of this,fornt.
23.Site diagram or additional well details:
,ar GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
• :::gin.only I G W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. .•,ta �5 ' SUBMITTALLrSTRUCTIONS
:well depth below land surface: (ft) 24a. For Ail Wells: Submit this form,within 30 days of completion of well
. •.,•..s i:s;all depths if different(example-3(a 200'and 2@I00') construction to the following:
;a'e water level below top of casing: 301 (ft.) Division of Water Resources,Information Processing Unit.
:•,:,:csir,, uae" 1617 Mail Service Center—Raleigh,NC 27-699_1617
6-1/4I '
3crc?oie diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24::
el
l construction above, also submit one copy of this form within 30 days of completion of well
.2.,;,utl construction method: construction to the following:
, . _ ... . . c.:ce.d:rec:push.etc.)
Division of Water Resources,Underground Injection Control Program. .
iZ w A T ER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
•?•.s id(epm) 7 9 Method of test: Air Blow 24c.For Water SuDDIV&Injection Wells: In addition to sending the form:to •
Chlorine (� the address(es) above, also submit one copy of this form within 30 days of
L'is niec for:type: Amount: W completion of well construction to the county health department of the co:t:li_.
where constructed. -
North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 22-2 i i t,