GW1-2021-08043_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:
Chris King At FROMToN�s DESCtt,M►oN
Well ContractorName 150& -L5 J,��fL
3415 fL ft
NC Well Contractor CertificationNm®ber l :fl CASING•(formulhrssedwells101tIs1NER t _ ble
FROM I TO DIAMETER THICKNESS MATERIAL
Gmn River Well&Pump fL fL ! in.
Company Name I(m..l1Y1VER CASING OR TUBING eetltermsl'i3uaed loo
2.Well Construction Permit#.- � ` t V©1 Qp�T"''� FROM TO D
& ft IAluE7ER THIC 21 MATERAL
6 rn 21 PVC
List all applicable welt permits f.e.Cormty;State,Variance,Injection,eta)
ft. ft. m.•
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM I TO DIAMETER SLOTSIZE TLICKNFSS MATERIAL
❑Agricultural ❑Municipal/Public & fL in-
OGeothermal(Heating/CoolingSupply) OResidential Water Supply(single) fL ft- in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&'GROUT.
FROM I TO MATERIAL EMPLACEMENT METMOD&AMOUNT
01rrigation 0 & 2D IL Salvete Mot&Pour
Non Rater Supply Well:
❑Monitoring ❑Recovery fL
injection Well: & S
❑Aquifer Recharge ❑GroundwaterRemediation 19,SAND/GRAVELPAGK da livable
FROM TO I NUTERIAL EMPLACF11IENMWEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fl- fL -
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control
20DRILLING`LOG(attaihadditionalshcersif _
OGeotheamal(Closed Loop) OTracer FROM To DFSCREMON(eator,hardnes%soiym k tyiW,R-i-sa,etc)
❑Geothe•rmal(Heating/Cooling Return) 00ther(explain under#21 Remarks) Q & 10 R RED
R 35: 'L AA J' $
4.Date N'ell(s)Completed: 7 Z Well 1D# r fL tL WIAT
5a..//Well Leo,cationn: R 5-R ^Ty
NIS �V0 ft. &
Facility/Owner Name Facility ID#(ifapplicable) & &
Rat fL fL
Physical Address..City,
-and Zap 22.:RB11fARiCS _
•�,�+vD'��In1 I`ll 'r� , 'l\ Ii , ' .
County Parcel Identification No.(PIN) _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: N O V - 5 2021
(ifweR field,one laidong is sufficient)
N 8Z �� i Z w Zi
Sitmature of Certified Well Connector Date
6.Is(are)the well(s): la Permanent or [7Temporary By signing this form,I hereby cerhfy that lire well(s)was(were)constricted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: Oyes or EINo copy ofthis record has been provided to the well mtner.
Ifthis is a repair,fill out known well construction information and explain the nahire ofthe
repair murder=21 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: t construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit one form r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: p 24a. For All Wells: Submit this form within 30 days of completion of well
For mmulhple wells list all depths f different(example-3@200 and 2@1001 construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:i 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:
(i.e.auger,rotary,cable,direct push etc.)
Division of Water Resources,!'Underground Injection Control Program,
FOR WATER SUPPLY FELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-106
i
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131L Disinfection type: HTH Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Disrision of Water Resources Revised August 2013