GW1-2021-08047_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
Chris King FROM TEItZO�fES,
FROM TO DlSCRrIP'I'lON
Well Contractor Name
V I
3415 R ft. E
NC Well Contractor Certification Number 35 UDTERt ASING,formulti-easeti.wells MUM
rf "liable): .
FROM TO DL11tIE1ER 7IIrCii I MATERIAL
Green River Well&Pump rt I R in. I i
Company Name 16.-INNER-CASING;URTItBING`(geothermal closed loo"
FROM DIAMETER THICKNESS MATEWAL
2.Well Construction Permit N. ��10 0 1 Z I y Z b t �r"m
6 ;n 21 PVC
List all applicable trey permits f-e.Cmmty.State•Ymiance.It jectian,etc.) R m
3.Well Use(check well use): ;17.SCREEN
Water Supply Well: FROM TO I DWIEI•ER I SLOT SIZE THICKNESS MATERIAL '
❑Agricultural ❑Municipal/Public H. it in.
❑Geothermal(Heating/Cooling Supply) 91Residential Water Supply(single) R R in.
❑industrial/Commereial ❑Residential Water Supply(shared) =18'CROUT '
FROM TO MATERIAL •EMPLACEMENTMETHOD&AMOUVr•
❑lrri tion 0 & 20 H' SaWete Mix&Pour
Non-Water Supply Well:
Monitoring ❑Recov R R
Injection Well: ft R
❑Aquifer Recharge ❑ mundwaterRemediation -�19_SANDIGRAV€LPAC-K rfs livable -
AL
❑Aquifer Storage and Recovery ❑Salinity Barrier FRO\t TO MATERI EMPLACEatENPME-MOD
R R
❑Aquifer Test ❑StormwaterDrainage R R
❑Experimental Technology ❑Subsidence Control
+_20:DRII1dNCLOC attach additional sheets if „•
❑Geothermal(Closed Loop) ❑Tracer FROM ID DESCREMON(tnlor,hardness,=WN ktr..grign. sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Othcr(explain under#21 Remarks) fL \i R 12DC ``
ii
Jo R ft Vi%,vv V^v It
4.Date Well(s)Completed: ( � ,�LWell ID# r - ft. 2—5-
� ft �•
Sa. iWell Location: 2- & G y it
ft. ft.
Facility/Owner Name Facility IDR(if applicable)
R R
Physical Address,City,and Zip
t� ;�—;� •21Ei11ARlLs -. -�� ai-
L 1 t N i/----Rw'� -'R
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/ntinutes/seconds or decimal degrees: 22 Cer6a' n
(ifwell field,one lat/long is sufficient) i
yL) N C1L � ZZ. ;JIU
J- W
of Certified Well Contract Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
Dv signing this form,I hereby cenh,that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A A`CAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the tre11 oumer.
If this is a repair,fill out knoum well construction information and explain the nahire ofthe
repair under'-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
8.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 some construction,you can
submit onefonn. SUBMITTAL INSTUCTIONS
t'
9.Total well depth below land surface: 90 (ft•) 24a. For All Wells: Submit this form within 30 days of .f 1.R.11
For multiple wells list all depths ifd(�erent(example-3@200•and 2@1001 construction to the foil..irig.
10.Static water level below top of casing: i 00 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
=r _.:n. - ........ .. address in R
24aabove, also submit a coy of _- -_-._ -• 30 d this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gym) 0 Method of test: Air 24c.For Rater Supply&Injection Wel[6,
Also submit one copy of this form within 30 days of completion of
131L Disinfection type: HTH Amount-'
mount well construction to the county he-lth department of the county where
constructed. 9
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
t