GW1--02473_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 1
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:.Well Contractor Information:
�h-stopher Greene o -f ag - -1, :45
...,r;;rae;pr\;:::: FROM TO DESCRIPTION
ft. ft. I I
2135-A •
ft. ft. i '
,4 t'.,::;caanr Certification Number I4445A4""v T0, ?--- r-� DIAMETER 71 T - .. '''T '.rt '-r.
A&F WELL DRILLING, AND PUMP SERVICE INC TER THICKNESS I MATERLAL
p ft. ft I �to
r.r. \,+
1331 L.I -041+55. _, : f .. :«
2.V.ell Construction Permit#: FROM TO DIAME I THICKNESS •i MATERIAL
,trpu,•.;i•i;mil construction permits(i.e. C'JC.County.State.Variance.etc.) • -ft. -ft. in. '
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:.F.ell 1 se(check well use): • ft. ft. in.
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t:a:cr tiuppi� Well: r. ' m' �� �=.'r ,- ''. ,„ -�xa,c'.
FROM ( TO DIAMETER SLOT SIZE THICKNESS 1 MATERIAL
•1..:;:i'•Urai DMunicipal/Public ft. ft. in. 1
`(;co(ircrn:a.:Heating Cooling Supply) OResidential Water Supply(single) ft. ft in. ' j
:tsi •
Commercial
.:atna:Commerl QResidential Water Supply(shared) 1 l
Y::_i;i;:i;on FROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
`.;in-V ater Supply Well: t/1 ft. CV ft. �idmixl poured
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s1iontiorinJ
�Recovery �./ ft. ft.
injection Well:Saw ft. ft.
•.�.:.::fcr Recharge EiGroundwaterRemediation ;
�sRL _ FK g7 O'73Ert +:4i,•Y_.hc'bx�R"c^,K`.? n %' :.0•••:
t A.::�:ter Storage and Recovery Salinity Barrier FROM TO I MATERIAL z i EMPLACEMENT METHOD
l\:.:i;er Test - QStotmwater Drainage ft. ft.
,ii!:xper: merra.Technology DSubsidence Control ft. ft.
1r.:0I c-n:...iCoosed Loop) Tracer _'^'= si;_ ? .
Return) (explain #21 Remarks) FROM TO DESCRIPTION(color,hardness.soWrock type.grain size.etc.)
isothermal i Heating/Cooling Other ex lain under ft. ft.
4.Date Well(s)Completed:LI-n-2024 Well ID# ft. ft. I - ` ..�a ',V
Weil Location: ^ ft. ft. A DO 2 r i�94
- - "bus-tin Toney - i ft. ft. r, ,
i Facility ID-(if applicable) `, .,. .. ....,_;,.,
ft. ft. ir,v i. ti
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►3g3 Salem Church Rol 3oshe, ft. ft. `L;'.
.: Vicires.,C:•
Iand Zip ft. ftt
uTheribrid
Parcel Identification No.(PIN)
s::.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
:•,s ell field.one at long is sufficient) 22.Certification: 1.
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W ,��„d,44• 447-202t1
scare)the wags) Permanent or Temporary Signature of Certified Well Contractor Date
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Br signing this form.1 hereby certifi•that The welI(s)was(were)constnaved in accordant e
-.:s:his a repair to an existing well: Dyes or No with 15.4.VCAC 02C.0100 or 15A.NCAC 02C.0200 Well Construction Standards and:rat a
.. .. ,:rcpa;r.rill wet known well construction information and explain the nature of-the copy of this retard has been provided to the well owner.
-. •cmur•ks section or on the hack of this.form.
23.Site diagram or additional well details:
or GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of thispage to provide additional well site details or svc
_,e ::.action.only i G1§'-1 isneeded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
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SUBMITTAL IVSTRliCTIONS
:. :'ctal well depth below land surface: 0905 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
.. : .:Ois list all depths if different(example-3(a;'200•and 2(a l00') construction to the following:
y
:::.Stack water level below top of casing_ 50 1 (ft.) Division of Water Resources Information Processing Unit.
.. . ..... .,:;n,e easing.use'•=' 1617 Mail Service Center,Raleigh,NC 27699-1617
- 61/4 i
Borehole diameter: (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
2.''ell construction method: construction to the following: '
. ,..,,i.::.ratcr:u.earl..direc:push.etc.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
a.Yield(rpm) 15 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
:?b.Disinfection type: Chl tine Amount: completion of well construction to!the county health department of the county
where constructed.
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: •- ••-. North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-22!t,,