GW1--06643_Well Construction - GW1_20241108

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WELL
CONSTRUCTION RECORD (GW-1) For Internal Use Only:
-1.Well Contractor Information:
Christopher Greene 1Av1 <r: ► 4`; f_.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2135-A
ft. ft.
NC Well Contractor Certification Number ieWOrraleik ';,,.' ,.
A&F WELL DRILLING, AND PUMP SERVICE INC FROM TO DIAMETER THICKNESS MATERIAL
O ft. ft. I in.
Company Name ,t '
2.Well Construction Permit#: 0123FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i• .e.UIC,County,State,Variance,etc) ft, ft. in.
-
3.Well Use(check well use): ft. ft. in,
Water Supply Well: alleWItrgy. r ,< "tiH •r a � H:w, xy .z,_.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural DMunicipal/Public ft. ft. in.
it Geothermal(Hcating/Cooling Supply) Egesidential Water Supply(single) ft. ft. in.
iIndustrial/Commercial DResidential Water Supply(shared) rx Ip , 0, , ftelftm` s,70 , W irdzra z r, uF.:p
1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. 40 ft' sandmix. poured
!Monitoring DRecovery ft. ft.
Injection Well: ft. ft. . '
(iAquifer Recharge DGroundwater Remediation
gl* A 1)11Cs`r t i? .ft`f,:ttfa*aiita1S lgZZSi iiii0W,40 r1,r, y .,,
. ;Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
!Aquifer Test DStormwater Drainage ft. ft.
U'Experimental Technology DSubsidence Control ft. ft.
;Geothermal(Closed Loop) ElTracer 7110011.} 1 T1+ trei#ch`(gtfdttbei slieeis zfdiee+ssi0~~1~'~~07, ',x l
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) ft. ft. '
4.Date Well(s)Completed:I0-25- Well ID# ft. ft. 1
5a.Well Location: ft. ft. ^ ^ -
G Iendale McDaniel ft. ft. t•.tate,.,...'A..: d3/ _
Facility/Owner Name Facility ID#(if applicable) • ft. ft.
WO aid DRive �ifnr bea NOV ® 2024
ft. ft.ft, ft. II,:,:;,:,,;:r%:t P-.^.^s✓..;!-.r.I1--.
Physical Address,City,and Zip
1:iu-fl'lerfad I(a387 ,I 3, N 'iA A . SeieU"'_•1'�F .JRVIORZa,k 'r'F� .bIgO'i;,W'(":i
County Parcel Identification No.(PIN)
,5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
c(if well field,one lat/long is sufficient) 22.Certification: '
N W
6.Is(are)the well(s) Permanent or DITemporary Signature of Certifi fd Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
' 7.Is this a repair to an existing well: ®Yes or XoNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a;
If this is a repair,_fill out known well construction information and explain the nature of the copy of this record has been provided to'the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For 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 well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'one SUBMITTAL INSTRUCTIONS
2 i
9.Total well depth below land surface: 30 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
—"_ —10:Static water level below opt of casing:40 - - ` -(ft:j-- Division of Water Resources,InformitttonProcessing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 •+1 Method of test: Air Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 34' Cha. completion of well construction to the county health department of the county
where constructed. 1
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2916• ,