GW1--03335_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ......„,...„
V,eie Contractor information:
7.r:stop^er Greene --_• ---' -....,J._ _
..r..,.;;a;\.:r.: FROM TO �,-DESCRIPTION
ft. ft.
2'35-A.
ft. ft.
.,...auon Number
.x:F 'WELL_ DRILLING, AND PUMP SERVICE INC FROM TO • D"Nc TER THICKNESS NIATERIA:.'
ft. ft. in.
:.'ii di Construction Permit z: I FROM 1 TO Df.»fE'rL3 THICKNESS MATERIAL _
i ..vrstructior,termite Ii.e. LIC.County.State. kOriance.etc.) f1. ft. is
. }°ell i se(check µell use): ft. ft. in.
:Cc:-Supply Well: : �..,. ..
FROM TO t DIAMETER i SLOT SIZE THICKNESS ` MATERIAL
DMunicipaliPublic ft. ft. in.
:.,,r ....;'Heating Cooling Supply) Residential Water Supply(single)
ft. ft. In i
:-i.:(..)-'-^c:c)a, Residential Water Supply(shared)
......_::t:,;r FROM , TO f MATERIAL i EMPLACEMENT METHOD&'.MOUNT
`•r.-}'rater Supply Well: 0 ft. ' ft. . u,,dmix I poured -
:'• T.ior:'g °Recovery ft. ft.
ion Weil:
sm.. ft. ft.
;:.• :c R e rge QGroundwater Remediation
A.::":r S /.age and Recovery OSalinity Barrier FROM TO MATERiAI. EMPLACEMENT METHOD
...••;�-- DStormwater Drainage ft. ft.
'x^.ri:r.e;tal Technology OSubsidence Control ft. i ft. ,
_ - - -
Ctosed Loop) Tracer " .i.,.•
FROM TO DESCRWTTIQN(aalati - typo,tide SW..*MI
,:.,,,a.i Heating/Cooling Return) [ Other(explain under*21 Remarks) ft. ft.
..:a:c WeIi(s)Completed:5'40'e 4 Well iDU ft. 1 ft. ) —
;ra`or. ft. ft. (`
1,1
JOr- C. NIo-gQ; MCSWair
Facility iDe(if applicable) I ft. ft. '- . 1
-Q)C?9 BRoad "Rivet N' lands Ivimreskern I ft. l ft.
c Zia ft. ft.
Parcel Identification No.(PIN)
.•...--::.titude and longitude in degrees/minutes/seconds or decimal degrees:
-.Or.t is sufficient) 22.Certification:
N
w � 5-10 -aoa/
'.. s.r.ro :hcwellts) 'Permanent or OTemporary tgnatureofCcnificdR'diContractor Date
Br signing this form•I hereby scrub'that the xelli. was(were)constructed in accoruar;
-.:s:his a repair to an existing well: QYes or )No with 13.4.VCAC 02C.0100 or 1SA.VCAC 02C.020o Well Construction Standards and ter:;.
.. . . .rii",at known x•ell construction information and explain the nature of the copy(O•th&record has been provided to the well owner.
. -. -:,mar;:s section or on the hark of this form
23.Site diagram or additional well details:
or Geaprobe!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::
-• t::.,:: a-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
��f SUBMITTAL L\STRUCTIONS
N.c;t depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
.::r depths if different/example-34200'and 2g/001 construction to the following:
i:ater level below top of casing: W U (ft.) Division of Water Resources,information Processing Unit.
1617 Mail Service Center,Raleigh,NC 27699-1617
. Borehole diameter: 6 1/4 (in.)
24b.For Iniection Weill: In addition to sending the form to the address ir.:4::
Rotary above. also submit one copy of this form within 30 days of completion of we:
.'..%ell construction method: construction to the following:
_ ..... .-c.,.direct push.etc.)
Division of Water Resources,Underground Injection Control Program.
: :N V%ATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
.`. cid t„pm) I Method of test: Air Blow 24c. For Water SuDDIv&Injection WeUs: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days or
pis nfec^or.type: hlorine Amount: completion of well construction to the county health department of the coca.,
where constructed.
• North Carolina Department of Environmental Duality-Division of Water Resources Revised,-11.,c'r.