GW1--03295_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
:.V.ell Contractor Information:
Dhrstopher Greene sIstr MtiMaim, .-
tor\3;^.0 FROM TO DESCRIPTION
ft.
2 35-A
ft. ft.
t ('orractcrC'ertification Number
F- WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAI.
Oft. 5o ft it
Sk123/211 - 0 Nos t O...:, -:. .: _� .rrER•:.
:.'++:i:Construction Permit�: FROM uTO DIAMFTFi THICKNESS MATERIAL
• It. ft. in.
..,..r;p::.'.;i•;,..,cell construction permits(i.e. CIC.Count.State. Variance.etc.t
.1t . CC' cheek well use): ft. ft. n.
ply �i ell: -,F'`s K,_ s`3_ • `:. -4
FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
°Municipal/Public ft. ; ft. in.
, :;Heating Cooling Supply) IResidential Water Supply(single) ft. ft. ' in +
omntc;cial ()Residential Water Supply(shared) _
...- ::i:,:r FROM I TO MATERIAL ' EMPLACEMENT METHOD&.ANIOUNT_
N:,r.-Water Supply Well: 0 fl. 010 ft• sandm x poured
:\`:,r:.:or:rf ()Recovery ft. : ft.
:ection Ni ell: —
—.. ft. ft.
,,,1A.. `. Recharge ()Groundwater Remediation 1,
�.A.. N . age and Recovery DSalinity Barrier FROM TO M cTERL<l , EMPLACEMENT METHOD
e ; ()Stormwater Drainage ft. 1 ft.
;::x;:':-::rental Technology ()Subsidence Control ft. , ft.
... -^.TMa:{Closed Loop) oTracer
"., FROM TO DESCRIPTION(color.hardness.soil/rock t,pe.Izmir,si>c.etc.
:.:,:o.L-enna.i HeatingiCooling Return) [Other(explain under#21 Remarks) ft. ft.
'
..Date Well(s)Completed:5•�I- Well ID# fr. ft.
..WC'.Location: ft. ft. _• , _
Edward N 4 Love lace Jr i ft. ft. ,~. I -.a....)
Facility iD=(if applicable) 1
1 ft. ft. 2024
I
BPsiaP,Tmklep e DaiVe lot l4 GArienFneSub. 1 ft. ft. i-1 t
and ZipV ft ft
RD i ilerford 1ta3S rlifl? 41410-reatill 'T.a.. .--'''. -.''.; '- - 0
Parcel Identification No.(PIN) _
_;:;de and longitude in degrees/minutes/seconds or decimal degrees:
—
c.u%..c:at icing is sufficient) 22.Certification:
N w � ��,/�.---� 5 -2 i - Zo 2�}
:he weilis)°Permanent or ()Temporar rgnaturt or Ce ihcd i ell Coc rector Date
By.signing this form.1 hereby certif that the xellttt was(were)constructed rn ucrordmr<<
:,a repair to an existing well: 0Yes or 'No with 1SA.VCAC 02C.0100 or iSA.NCAC 0?C.0200 Well Construction Standards and i/tul:.
art knot,n xc/I curtstruction information and explain the nature of the
copy of this record has been provided to the well owner.
_ ,r::rka section or an the hack of this form.
23.Site diagram or additional well details:
-or C;eoprabe/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:
:::0^E I OW-1 is needed. Indicate TOTAL NUM)3ER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL LNSTRUCTIONS
•. ...tar 1% :i depth below land surface: �5, (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
.s e.st all depths if different terampie-34200'and'a 100') construction to the following:
. S,:a ie water level below top of casing: LA' (ft.) Division of Water Resources,Information Processing Unit.
rasing.use.. 1617 Mail Service Center,Raleigh,NC 27699-1617
::.Borehole diameter: 6 1/4 (in.)
24b.For Iaiection Wells: In addition to sending the form•to the address in 24.:
Rotary above.also submit one copy of this form within 30 days of completion of,c..:
:2.V.ell construction method: construction to the following:
. . _ ... direct push.etc.)
Division of Water Resources,Underground Injection Control Program.
r,)1R V.ATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
?-.1 ield t„pm) 1 5 9pm Method of test: Air Blow 24c.For Water SuDoly& Infection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
=.I.:iisinfectior.type: Chlorine Amount: 3t ( completion of well construction to the county health department of the county
0 where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised'--22-2''.!r.