GW1-2021-08051_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or mu p e is
1.Well Contractor Information:
Chris I(ing ia�vATERzaNES
FROM TO I DESCRIP1710N
Well Contractor Name & fL
3415 R. fL
NC Well Contractor Certification Number S:OUTERGAS7NG fo%mul6esud yells ORTiNEIt Ufa' Lk`
FROM TO DUMEIFR THICKNESS MATERIAL
Green River We1181 Pump • &
Company Name 46:MERGASING OR.TUBING` dosed boo "_
FROM TOI 111AMEM I THICKNESS MATERAL I -
2.Well Construction Permit#: 1 1 n 3A Z Vft- 6 in 21 PVC
List all applicable well permits ft e.Cota ly�ate,T'arrance,Injection,eta)
R ft is.
3.Well Use(check well use): ,17.'SCREEN
Water Supply Well: FROM TO D1M MIt SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic IL It in.
❑Geothermal(Heatmg/Cooling Supply) in Residential Water Supply(single) $ tI in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUYr
01nigation 0 il• 20 (L Sa(rete Mix&Pour
Non-Water Supply Well: f ft
❑Monitoring ❑Recovery
Injection Well: R• &
❑Aquifer Recharge ❑Groundwater Remediation Y9:SAND/CRAYEL.PA(K'rfa' Unable
IINP
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I.ACEa1ENT MEI4IODR R
❑Aquifer Test ❑Stormwater Drainage & &
❑Experimental Technology ❑Subsidence Control
':2011RQ.I:UYGLOG stta�aiddiGoual:stitets'if" ", _, ;, ..
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCREMON(color,hardness,saWrml,type,tram sim eta
❑Geothermal(Heating(Cooling Retum) ❑Other(explain under#21 Remarks) p
L
C' ft R
4.Date Wel(s)Completed: -J o Well 1D# � Q �35 rthft-tIs CAEOL �
Sa Well Location: r 35 R I Ill
^ 1
9w 11, Wu
y- G p� 8. fL l•
Facility/OwaerName Facility ID#(ifapplicable) ft R
2316 Svmmoz Rv fL ft , t
Physical Address,City,and Zip 21:,RE1VIARKS - ' 71 ,.-
t-lErvo�RScrrJNOV 2021
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minrtes/seconds or decimal degrees:
(if well field,one Wang is sufficient)
Cer
N W Jr
Sig6ftf=of Certified Well Co r Date
6.Is(are)the well(s): OPermaneat or ❑Temporary By signing this form.I hereby certify that the well(s)was(wire)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RINo copy of this record has been provided to the well owner.
If this is a repair,f fd1 out known well construction information and aTlam the nahrre of ibe
repair tinder=2l 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 mlechan or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 105 (fL) 24a. For All Wells Submit this,fom r within 30 days of completion of well
For multiple wells list all depths ifily rent(example-3�arndd22@100) construction to the following:
1Q Static water level below top of casing: 00 Division of Water Reso'orces,Information Processing Unit,
Ifwater level is above casing,rise '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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:
(i.e.auger.rotary,cable,direct push,etc-)
Division of Water Resources,iLrndergr•oand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
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
136 Disinfection type 1'ITf 1 Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013