GW1-2021-08046_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 IGng :�a�r*�
FROM TO I DESCRIMON
Well Contractor Name R R
3415 f. &
NC Well Contractor Certification Number
IS'OUTER EASING for"iuulh cage3"'efts ' rE"` fable
FROM To DuatETER TalclavFss MATF]t1A1.
Green River Well& Pump i
Company Name I6liVNEIt,GASINC:'blt+YtJBIIV Hosedloo
� FROM TO DrAats-rFa TtllL'ICNFSS MATratet
2.Well Construction Permit#: ZO i Z0 11,1© k R 6 1O 21 PVC
List all applicable well permits 4a County,State,Variance,bjeWoA etc)
fL fL in.
3.Well Use(check well use): 17__SCEE44. .,
Water Supply Well. FROM To DtAt1tETER SUMSI7& TBICKNEsS I IOA7'ERIAL
❑Agricultural ❑Monicipal/Public ft• ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft is
I8 GROUT_ :_
❑lndustriaUCommercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 fL 20 ft- Sakfete Mix&Pour
Non-Water Supply Weil
fL R
❑Monitoring ❑Recovery
Injection Well: ft: &
❑Aquifer Recharge ❑Groundwater Remediation %19;> iD%CItALAGK da Ticable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
fL EL
❑Aquifer Test ❑Stormwater Drainage & fL
❑Experimental Technology ❑Subsidence Control
20:11RIL)LING70G attaclb,additionalsheetsd'"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(color,hardnem,soiUrorkt sar,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft (� ftBig) 1,64
l
4.Date Well(s)Completed: L 'I-well lD#
5a Well Location: j..i 5 fL —1 1 J is , R r , .i > tL-c
R ft
Facility/Owner Name Facility 1D0(ifapplicable)
5,4/ N fL ft.
Physical Address City,and Zip .21 REMARKS•;::-
i-�GN1�c�SOYJ k1
County Parcel Identification No.(PiN) NOV
C
20-21
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 21 Certification: tl
(ifwell field,one latllong is sufficient)
15 Z N FI ( � 1, (Q 10 W ' 3 `2
of Certified Well Contrace1h.1",he
Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby cer< wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weth ❑Yes or BNo copy ofthis record has been provided to the well owner,
if this is a repair,fill out brown well construction information and explain tyre nahire of the
repair rider t2l 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 ONLPwith the same consttuedon,)vu can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: i&0 (ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(tt)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,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 00-) 24b.For Iniection Wells ONLY:j In addition to sending the form to the address in
24aabove, also submit a copy of!this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(ie.auger,rotary,cable,direct push,eMJ
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
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
13b.Disinfection type: HTH Amount, well construction to the county htalih department of the county where
constructed. I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Rmounces Reused August 2013
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