GW1-2021-08050_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD
For Internal Use ONLY:
lltis form can be used for single or multiple wells
1.Well Contractor Information:
JWMATERZipPiE$ :' r
Bryant Smith FROM TO DESCIUMON
Well Contractor Name M ft
2571 & ft.
NC 15=:OU rEILCtI S1!!TC for miiltreiseil eve"II.s ORUNER if a'e CotrttactorCertificationNtanber _..._..;..,,
FROM TD DTAI1tE1'ER THICKNESS MATERIAL
Green River Well &Pump rt. fL in
Company Name .
p `.�� r e� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2, ! Q 1 O/V if I ft: ft g in 21 PVC
List all applicable well permits(i.e.Co=D4 State,Variance,b jection,etc-) 1 .39
ft. & in.
3.Well Use(check well use): =.17.';SCRSEN
Water Supply Well: FROM I TO I D1AINSI'ER SL ITSIZE I THICKNESS I MATERIAL
❑Agricultural ❑MimicipaVPublic & ft in
� I —+
❑Geothermal Heating/Cooling Supply) OResidetial Water Supply(single) & ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,."&T GR01If r " z
FROM TO ~MATERIAL EMPLACEMENT METHOD&AMOUNT,
❑Frei tion 0 fL 20 ft' Salmete MDc 8r Pour
Non-Water Supply Well:
❑Monitoring. ORecovery R M
Injection Well: ft &
❑Aquifer Recharge ❑GroundwaterRemediation 19:'SAND/GRAVL7,PAGR rfa 71cg61e
�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EM1TPLACEMENTMETROD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
30sDRILLIlYC3AG attaeLadditio"n'al'stieets�f
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,wiyr k qVe, etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it fL 3;
fLft.
4.Date Well(s)Completed: �,—f z� Well 1D# 2 &
1 i��• !�,
Sit Well Location: R &
ft. M V 5
Facility/Owner
�NQame Facility IDk Wapplicable) & ft
7,( /'I 1 aJ�/ 4 i9 iZ ft. fL
Physical Addiess,City,and Zip
!fir iJt�)iit iox/ , ,-?,F 1 i `'ize 9 o '71)1
County Parcel identification No.(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 21 Certification•
(ifwell field,one[at/long is sufficient)
3�`' 2-2 ` 102_ N�`' 15 ` 16 W 13tiro 2--JO-Zr
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this fora,I hereby certify that the we11(s)was(were)consimcred in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Conslrxetion Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo coPi,of this record has been provided to lire well owner.
If this is a repair,fill out known well conshwc1ion information and explain the nahtre of the
repair render-21 remarks section or on the back of this form. 23.Site diagram or additional well detail[:
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 supph,wells ONLY with the same construction,yw can
submit oneforni. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70g (g,) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200•and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 0-) 24b.For Injection Wells ONLY: In addition to sending the fort 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,;;c
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
6
13a.Yield(gpm) r 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 health'department of the county where
constructed. II
Form GW-1 North Carolina Department of Environment and Natuial Resources—Division of Water Resources Revised August 2013