GW1-2021-08042_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For hdemal Use ONLY:
This form can be used for single or multiple wells
1.Wen Contractor Inrormation:
Chris King l4 iVA3ER2()LV
FROM TO .DESCRIPTION
well contactor Name ft. tz
3415 fL fL
NC Well Contractor Certification Number 1 OUTER;CASING fiieni L estedilells OR3sfNER da "b[6
FROM TO.. DIAMETER, THICKNESS MATERIAL
Green River Well& Pump rL fLHL
Company Name IS'lNNER' 1S11VGORTItBING rtosed�uo'
<<�, �ry f� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: r:I i 00 V �. \J `1 fL s� B, s in 2� PVC
List all applicable well permits(i.e.Counry,State,variance,it jection,etc.)
fL ft. in
3.Well Use(check well!use):
17`SCREEPT r
Water Supply Well: FROM TO I DIAMETER i SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic fL R. in.
❑Geothetmai Heatin Cooli Supply) OResidential Water Supply(single) ft & m
( g/ og uPP Y) uPP Y l gl )
❑hidustnal/Commercial ❑Residential Water Supply(shared) 18 1,tOt1T
FROM I TO I MATERIAL EMPLACEaiENT 11TE1'HOD&AMOUNT•
Mitigation 0
Non-Water Supply Weil: ft 20fL Salvete Mac$Pour
❑Monitoring []Recovery R R
Injection Well: fL &
❑Aquifer Recharge ❑GroundwaterRemediation 19-SANDICRAVELPACK if.n licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FRoal TO MATERIAL Er-WLACEMVVT 11tETFIOD
IL tL
❑Aquifer Test ❑Stormwater Drainage & fL
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer MRIII TO:IlYYOG atl8eb DESCB�l7osbNe(�mslar tuna aess.saNmrk t sue,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft fL
ft — ft
RE S
4_Date Well(s)Completed: 7-3 Zlf' Well ID#
L15 fL '3c35� U y
Sa.Well Location- fL
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p�ic�A ivD IL ft.
Faci ity/Owner Name Facility Mff(ifapplicable) h fL
Physical Address.City,and Zip
v�tn �LSCfV NOV _ 5 1021
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficien)
22. oft:
uZ2 37W :!Z
�-23 Z
mCertified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby eerrfy that the well(s)xas(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under ell 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 mW13,wells ONLY with the same construction,you can
submit one form. 2 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: )U (ft.) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 t@r 100) construction to the following:
10.Static water level below top of casing: LI ((}) Division of Water Resources,Information Processing Unit,
Ifuater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (ia) 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:
O-e.anger,rotary,cable,direct push,—)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) z Method of test: Air 24c.For Water Supply&Injection iWells:
Also submit one copy of this form within 30 days of completion of
136 Disinfection type PITH Amount well construction to the county health'department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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