GW1--02938_Well Construction - GW1_20240513

i.,
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: 1;H ' . .• .
'...Weii Contractor Information: 11 ' , .
.•
stopher Greene -_-.__
FROM ; TO —DESCRIPTION
... .,,r::r:.;;,,r\.:,:re
' ft. I ft. [ I 1
ft. 1 ft.
'. ... (',::;.-:ic:c.r Certification Number
‘c:.:{-,4....-',/•=:•7'..J.,'''''..•,...'"-.-:?'''•-•;'-"---..'i.:::-.."".!'`' --. : -.I 77..''::'*--:.'-'.r'n'r:P.;,':/, ';'-: :•
WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL '
0 ft. . ft. . .in.
- •"'Nnv\.1,-.1.= , .1. Construction:Permit* • . - (A .,,,.,.....,...:,_,.,,..77,:,..7.:,._ ......_„:„...-.7.-,--:----7-7.' _ . - .- ••-:,:'. ,•.,.,--•,•'.1,..,-22•1'.-. "„kn'''-:-• f
FROM ' TO )LTTFI AMELW . XIGNESS MATERIAL:,, ••.
• . ...,,p;,.:....-c,:c!!canstruction-permitX li.e.L7C.-"Calinty,State. Variance;etc.) — : ' - ft• • ft.-. . -
• ,
.- ell 1.se(cheek well use): ft. 1 ft. in.
Miti**00StrW. - . -
,'•a:cr Suppi Well:
FROM TO DIAMETER SLOT SIZE TifICICKESS I MATERIAL
I •'. :,:%::••,:rn..a:;Heatine Cooling Supply) Residential Water Supply(single) ft. I ft. . in', i i
--, . l_
.••;— •.•,:a'Con,,c-cial •DResidential Water Supply(shared)
.....7:eatIon FROM I TO r MATERIAL - -I-EMPLACEMENT METHOD St AMOCNT_
's•;n-V...a ter Supply Well: 0 ft' .070 ft. sandmix II : poured
DRecovery ft. ft. • . i ,
i •
. ,
];:j ection'Well: .•:.3“.,,.::,:::.Rot:nava' •• DGroundwater Remediation _,77,2,..: 1„: ,-.„-: •
..A :;:7,2r Storage and Recovery • OSalinity Barrier - FROM I TO MATERIAL 1 EMPLACEMENT METHOD
•t ,,ft.- . ,‘.:••s'er Test , DStormwater Drainage -, ft. I
er1711tria:Technology . ciSubiidence Control ft. ft.
.::,..,:.:i•.:2,7:-.a:i Closed Loop) , OTracer ;;N•t',:;•-.-'.:: •-T.,.-...:•-l-—-.' -,:-' •'7`;-,,,. '.-.:-:, -•-• ...,_,:::..-• :--v!:.,..:- .1..";:,,.M4g;-.i.: ,
FROM DESCRIPTION Itodness.seal/rock type.grain size.ere.'
Heating/Cooling Return) DOther(explain under#21.Remarks) '
ft. TO ft. (color.I ''
Well(s)Completed4"23"282.11- Well ID# i. ', ;,
,. •:-._',.. .-:0
4....V.V.:7..ocstiort:
— 2
ft.
• ft. MAY 1 024
ft.- . ••, i p.:.:!e7\amo . ,: -: s: '. Facility IDe(if applicable) ft. Ir,f,ar.r;i.l.'t':-.. 7'-,-1-.!..7.7;-.:3 1,111i.
. I .
DeAD END RDAD(Nerl- 4r) 0 ,/90) 1 ft. ft.
. •• - • • ft. ft. • .
PRilther0 1(05Ia baI - ! - - --titrson-7,- . .
Parcel Identification No.(PIN). 1 , •
:_2tittille and longitude in degrees/minutes/seconds or decimal degrees: I
_ •..,...:::N:i.i.one ..ii.long.is sufficient) '22.Certification:
.. ... _. .
., .
N .
. I, :: : * 1060,23'ail-
. . . ,.
Signature of Ccrtificd Well Contractor Date:si,a,re)thewell(s)giPermanent or Temporary
signing this form.I hereby cert")5,that the we'll:))was(were)constructed in Fc•ordan,,,
-.:s:his a repair to an existing well: laYes or IgNo with/5.4 SC.-le 02C.0100 or 15.4 AlCAC-02C.0200 Well Construction Standard,and tha:..
• i.•,....s pco•nr.till•sat known well construction information and explain the nature of the copy of this record has been provided to the well owner.
•,.• :,:.• :.T1711.irkS section or on the hack of this.form. .
23.Site diagram or additional well details:
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 we:i
•.7or
..,•:-....:.:iion.only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
. SUBMITTAL INSTRUCTIONS
well depth below land surface: " 01,15' .. .
(ft-) 24a. For All Wells: Submit this Iform within 30 days of completion of well
• ::...,.. •,,,.:s Ls:all depths if different(eXample-3(k200.and 2@1 00'1 I:
construction to the follov6ing: • -
Q
- ...-,.::-.':'.z-v.-.2 ter level beloW.MP of casing:' .J ? - - (ft.) Division of Water Resoutces,Information Processing Unit.
...• :,..h.,......casing.use" 1617 Mail Service Center,Raleigh,NC 27699-1617
1:.Ban:hole diameter: 6 1/4 (in.) • 24b.For Injection Wells: In addition to sending the form to the address in 24c
Rotary above, also submit,one copy of this form within 30 days of completion of well
:2.Vs cii construction method: construction to the following:
direct push.etc.) .
Division of Water Resources,Underground Injection Control Program.
W ATER SUPPLY WELLS ONLY: , 1636 Mail Service Center,Raleigh,NC 27699-1636
-. .Yield(gpm)Zorgborine Method of test:_ Air Blow
24c.For Water Supply Si Iniection Wells: In addition to sending the form to
the address(es) above, also submiti one copy of this form within 30 days of
hl '
.:::.7,isinfecrion type: Amount: completion of well construction to Ithe county health department of the county
1 .
where constructed. I
I;
North Carolina Department of Emironmental Quality-Division of Water Resources , ! Revised 2-22-2n is