GW1--03190_Well Construction - GW1_20240524

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: � iiimia.i"'
:.V.eii Contractor Information:
C7-s.7`stopner Greene i :;; „ -
FROM TO DESCRIPTION
ft.
2 35-A
—
ft.
c: (..:., to•Certification Number _
.L,&F WELL DRILLING, AND PUMP SERVICE INC FROM TO ry'"c-ER THICKNESS NATERt :
C 0 ft.
ft.
• ... ..a::v\a^u
-.W.ell Construction Permit# I FROM TO DIAMEl' THICKNESS ctA-E Rlai
....., .,.i,urstruction permits tire. L7C.Count.State.Variance.etc.) ft. ft. in.
t
IA ail t se(check well use): R. ft. in.
a:cr Suppy «ell: FROM 1 TO I DIAMETER SLOT SiZE THICKNESS MATERLAI.
\�. .:.,.. .:: DMunicipabPublic rt. ft. t in. I
,:::Heating Cooling Supply) Residential Water Supply(single) ft. ft. in.
Commercial cial Residential Water Supply(shared) _ _
l::'aLt:CR FROM ! TO I MATERIAL i EMPLACEMENT METHOD&AMOLV"
N.,,n-Water Supply Well: 0 ft. 4 fr. 1 sandmix pcuree
\.l.'7.",:k>':':, ®Recovery ft. ft. J
injection Weil: ''
ft. I ft.
A,•:...:r Ree ar_e DGroundwater Remediation
itliiiA;..':r Storage and Recovery QSalinity Barrier FROM i TO , MATER^A 1 EMPLACEMENT METHOD
_Cr Tr.., DStormwater Drainage ft. ft.
,F.xperimenrai Technology DSubsidence Control ft. ft.
": eo:lcina:?Closed Loop) DTracer , toit; '- -'
FROM TO i DESCRI?TFO\t color.hardness.soil/rock nor..,ralc Alec,etc.
�..:,:o:h::r:;a:i Heating/Cooling Return) [Other(explain under#21 Remarks) I ft. ft.
..;air R'eil(s)Completed:54D' 4 Well ID# ft. ft.
i.ocadon: j
ft. ft. .
I -J L...T -...wf
Joel ! MQrTann M ft. ftC5Wain .
^^nn-•',"\^,,,,J '7� �p u )^„Faciilliit iD:(if applicable)
ft. ft. MAY 2 r 20/4
(0N`i U R ivei 1 , `ond Mccresimrnf ft. ft. l r#.> ...z t's: ^. ,. s>:=.�'3rJi
L Z ft. ft. G.fi•.0!AtJv
CIe i t Jonc �-..; .:.: -
Parcel Identification No.(PIN)
_...:ude and longitude in degrees/minutes/seconds or decimal degrees:
ore:at ion_is sufficient) 22.Certification:
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G ,� 5 .ID -aoaii
-..N,sr a)the well;s)'Permanent or OTemporaty Signature of Certified Well Contractor Date
Br signing this form.1 hereby certih that the Isr1119 was(were)constructed in accorriac;,
- •-i..a repair to an existing Nell: Dyes or ONo with 15.4.\'CAC 02C.0100 or/SA.NCAC 02C.0200 Well Construction Standards and that c
., o,;rr.till out known xcli coactruction information and explain the nature nf the cope of this record has been provided to the well owner.
.. -, -,,marks section or on the hark of this 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 we::
,...:` .::..et.o .0;i'IOW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
,: loJ
��f SUBMITTAL INSTRUCTIONS
.. :'eta!well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
• : ,.,r•s:all depths if different(example-34200'and 2@100') construction to the followine:
. eta lic water level below top of casing: Co O (ft.) Division of Water Resources,Information Processing Unit.
using.use' 1617 Mail Service Center,Raleigh,NC 27699-1617
::.Borehole diameter: 6 1/4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 2::
Rotary above, also submit one copy of this form within 30 days of completion of wei
:2.to ell construction method: construction to the following:
. r ... carte.direct push.etc.:
Division of Water Resources,Underground Injection Control Program.
F;)R«k ATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
:? .Yield(rpm) ' Method of test: Air Blow 24c. For Water Sunray&Injection Wells: In addition to sending the form :o
the address(es) above, also submit one copy of this form within 30 days of
?:).Disinfection type: hlorine Amount: completion of well construction to the county health department of the court.
where constructed.
••-. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2(1 t.