GW1-2021-08040_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
i `� (�
_ FROM TO DESC RIM ON
WellComtactorName fL tt i
3SJ t R R
NC Well Contactor Certification Number
FROM TO DIAMETER TMCKNESS MATERIAL
' G RF,FN RIVER Q' Fume R R in.
Company Name 1611I�QV$RCASINOOR; OBllVG' col�sm!'tlacedloo a f
2.Well Construction Permit#: Z 1 1 �J/�Q I O L4 LA R 1 FROM' R TO DtAMerERR 6 uL TwcxNEss MAiElwl._.
List all applicable well permits(i.e_Comity.State,Vartanee,lyection,eta) 2� PVC
R R in.
3.Well Use(check well use): Kz
l 7 SC1tE Q5.>
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKN&43 } MATERIAL
❑Agricultural ❑MunicipaMblic R R in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R R in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT MEIROD&AMOUNT
y
[]Irrigation 0 R 20 R Sawete Mb(&Pour
Non-Water Supply well: R R
❑Monitoring ❑Recovery
Injection Well: fL R
❑Aquifer Recharge ❑Groundwater Remediation 19 SiDICR11i$tiYiYCK der"'lieitbk ; t,.v
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMl'IACEMtNPI MEIAOD'
R R
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
2rys))liII.LIlVG=1OCr ttddihqualstaxt3t'"
❑Geothermal(Closed Loop) []Tracer FROM I TO DISCRIPTION(color,badv®,3"roek mm Arain sue,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f R Sowa!fLO
R R
4.Date Well IL-1/1 Completed: ,l(7 4 We6ID# R ZQ R jRN6L d-�
Sa.Well Location: R
Facft,/Owner Name Facility W#(ifapplicable) R R
2 lq Z Y1rl 117DL IZ' Lrr fL
Physical Address,City,and Zip
FNaEce,�a N
County Parcel identification No.(PiN)
5b.Latitude and Lo tude in d minates/seconds or decimal degrees:
(ifwell field,one laUbnQssufficient) G 22 Certifigafion:
N �2 i 1 © t W l �J
Sibmature of Certified Well Co IF D
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well• ❑Yes or BNo copy ofthis record has been prmtided to the well owner.
JThis is a repair,fill out brown well construction information and explain the mature of the
repair under 1-121 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: 20 S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells liar all depths if different(example-3(a)200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter. 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(Le.enter,rotary,cable,direct push,etc.)
Division of Water Resources,�Undergroand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Au- 24e.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county health department of the cotmty where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised Ausarst 2013
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