GW1--03334_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ""—
: v eli Contractor Information:
•
a7.7istopher Greene r= stisw- 'It ..4.
_.,,.,tnr\,;t^� FROM ' TO DESCRIPTION
f:. ft.
2`35-A
ft.
,1.. (',..,.,ace Genf ica;ion\; ..
&=WELL DRILLING, AND PUMP SERVICE INC FROM TO • DIAMETER THICKNESS Mi-ER:A:
0 f.. II • ft. it.
•
... \,?... " Ili 4- :•. «... ostsv,• s ..:rat. ,,,, -,_ .
:..A eii Construction Permit : FROM TO ' DIAMET`, THICKNESS MATERIAL
• ....,rn::.•,tide:Id!construction permits Me. L'IC.County.State, i'oriance.etc.,
ft. in.
i.P.ell I.se(check well use): ft. ft. ' n.
;t , :
ate:Suppl Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ OMunicipalfPublic ft. ft. in.
;rt le;-:a:;;Heating Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
�� .s.ne:C, N ommercial Residential Water Supply(shared) T3;- -.
�/-Brief m ri FROM TO MATERIAL EMPLACEMENT METHOD&.AMOCN1_
;r,-W ger Supply Well: O ft, O�V A0 rt. sandmix poured
-_\i:,;ttor:ne Recovery ft. ft.
:ection Well:
ft. tr.
.,k..•:: K --ate jGroundwater Remediation
.- ; ee and Recover}, [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
, ElStormwater Drainage ft. ft.
., -. ..,rtaiTechnology" E3 Subsidence Control ft, 1 ft,
:herr.•.a,tCoosed Loop) DTracer �; r_i"' "?�....;V 1 M' >:= .
7FROM TO DESCRlPTiON(color.hardness.soiIirock npe,:rain ci4�•,etc.
:.,::o:hermii:i Heating%Cooling Return) [Other(explain under#21 Remarks) ft. ft"
.,;ate Weil(s)Completed:5'29'2024 Well ID# ft. ft.
.. ...Location: ft. ft.
alna—RaMSEULD_OI.15_ ft. ft. i r,+.
Facility ID=(if applicable) ft. ft. V f 2024
PO 18 _rYiefon R1)� K1rb3stown NC a 8150 ft. ft.
.andZip ft. ft.
(ere land
Parcel Identification No.(PIN)
__:.::::inv and longitude in degrees/minutes/seconds or decimal degrees:
—
r.c:at long is sufficient) 22.Certification:N
��pp 'r
W 5`d !"o
-.. ,,.s-:)the wells) Permanent or OTemporar} tgnature of Certified Well Contractor Date
Be signing this form.1 hereby certif'that the welliy was fwerei constructed in ac•cordaner
-.:s:his a repair to an existing well: 0Yes or EINo with ISA.VC.4C 02C.0100 or ISA,vC.tC 02C.0200 Well Construction Standards and Mat;:
,:ivsair.r%;f•net known well construction information and explain the nature of the cope of this record has been provided to the well owner.
... :,.•. -, -;,marks section or on the hack of this form.
23.Site diagram or additional well details:
-nr Geoprabe/DPI or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
_,.:.....::.a;.,::: 'I Gib`-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Qn_P SUBMITTAL INSTRUCTIONS
C i
•. :eta!well depth below land surface: 6 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
. . .• . . all depths if different texample-3(4200•and 2 4,100') construction to the following:
i:atie water level below top of casing: .3 (ft.) sion of Water Resources,Information Processing Unit.
casing.use . .30 Division
1617 Mail Service Center,Raleigh,NC 27699-1617
::.Borehole diameter: 6 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24e
Rotary above, also submit one copy of this form within 30 days of completion of weft
: si ell construction method: construction to the following:
, . . ..... . direct push.etc.)
Division of Water Resources,Underground Injection Control Program.
:)R ii:A T ER SUPPLYLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i ield tgpm) I00,I npm Method of test: Air B1ow 24c. For Water Suoniv&Infection Wells: In addition to sending the form to
ChloJrine � the address(es) above, also submit one copy of this form within 30 days of
d 3//W b __ completion of well construction to the county health department of the counts
Y where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2%I 6