GW1-2021-08045_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For internal Use ONLY:
Ibis form can be used for single or multiple wells
1.Well Contractor Information:
Chris King All
FROM TO DFSCRIMON
Well Contractor Name f4 ft.
3415 IL iz
NC Well Contractor Certification Number 1X) CASINt; forelataselw ORd?fIELE rr`
FROM I TO 1 DUMErER 'ffiCti1VES5 MATERIAL
Green River Well 81 Pump tL IL I in.
Company Name 16 1NN£1tGAS! G O 1-I)B1NG. edthsml;I oo `
i r FROM I TO I DIAMETER R THICKNESS I MATERIAL
2.Well Construction Permit# ZJ 1 l fL EL6 m
21 PVC
List all applicable well permits(t.e.Cmwy,State,Variance,Injection,etc.) & ft. is
3.Well Use(check well use): .
Water Supply Well- FROM TO DIAMXMR SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public & is
❑Geothermal(Heating/CoolingSupply) OResidential Water SuPP1Y(single) & & rn
❑IndustriallCommereial ❑Residential Water Supply(shared)
FROM TO "MATERIAL k EMPLACEMENTMEI'HOD&AMOUNT
Non- on
Supply Well: M
❑ on p & 20 Salmete Mot&Pour❑Monitoring ❑Recovery & ft.
Injection Well: & fc
❑Aquifer Recharge ❑GroundwaterRemediation -=,SAWDJGRAYRLPACii
MATERIAL ..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO� FL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R
❑Experimental Technology ❑Subsidence Control
>20;:DRILT.IIVG_[AG:Yattaetiadditionslshi:etsif"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRD'TION1robr,hardness,suWrw, sse,e1c.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL InfL
R & I
4.Date Wells)Completed: Well too 2_ fL
Sa.Well Location:
Facility/Owner Name Facility lD#(ifapplicable)
1A >t f
Physical Address,City,and Zip
County parcel ldentificatiopNo.(PFN) NUV
s 202
Sb.Latitude and Longitude in degrees/miootes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22 zz
f
T � 1 21 N i�Z W Zi
Si6mauacofCerified Wel�L.r Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,f herebp that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9lNo copy of this record has been provided to the well owner.
Ifdds is a repair,fill aid known well construction information and explain the native ofthe
repair tinder'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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the satire conshvichan,you can
submit oneform. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: ill ) (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For andiiple wells list all depths ifdii erent(example-3Q200'and 2 a@100) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
ffivater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in-) 24b.For Iniection 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.auger,rotary,cable,direct push,etc.)
Division of Water Resources,(Underground Injection Control Program,
FOR'WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) � Method of test:
Air 24c.For Water Supply&Injection Wells:
HTH Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Amount: well construction to the counh'health department of the county where
constructed. !
Form GW-1 North Camlma Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i