GW1-2021-08056_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 4,<akAfiER'ZON
FROM I TO =I DESCRIPTION
Well Contractor Name t9 L�.
3415 R
NC Well Contractor Certification Number I5� 1)TER'fASII!tG.for mattteakeitAells:)R7IlVElt. ble
FRO141 TO DIAMETER THICKNESS MATERIAL
Green River Well& Pump & rt in.
Company Name WJNNIWCASINQQRTURING' " etiied-too"t,
i FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Zl ft t 3 fj ft 6 is 21 PVC
List all applicable well permits(e County,State,Variance,lryecvfon,etc.)
ft ft. in.
3.Well Use(check well use): •j7t'SGREEN•
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL >.
❑Agricultural ❑MunicipaL'Public % ft. In
❑Geothermal(Healing/Cooling Supply) aResidential Water Supply(single) ft ft m
❑lndustria/Commercial ❑Residential Water Supply(shared)
FROM TO MATERL -EMPLACEMENT'ME HOD&A M Ot1NT
Non-Water Supply Well:❑ 0 & 20 a IASalvete Mix&Pour
& ft
❑Monitoring ❑Recovery,
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 49.SAND/GRrfV=-TACK fif a p plicii FROM TO MATERIAL 61e
EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
Test ❑StormwaterDrainage R R
❑Experimental Technology ❑Subsidence Control
WDRII.tMC OGi attaeliadditimudshee"tsifri
❑Geothermal(Closed Limp) ❑Tracer FROM TO DESCRIPTION(color,bardness,sdVrmkt Sim etc.)
❑Geothermal(Heating(Cooling Rctum) ❑Other(explain under#21 Remarks) Q fL ft c
ft R
4.Date Well(s)Completed: Z Well ID# wi
5a.Well Location: ft ft zRowyV
ft ft
1•W� �Q��L� rt
Facility/Owner Name t Facility ED#(if applicable) n ft ft � _
rNf- M ft `N. A "e e.
Physical Address City,and Zip54
21."t2EMARKS
INV
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
i
(ifwell field,one lattlong is sufficient) 22.Certification: li.'fC�;�,,1,aT1���
�1 �L") �� N S5 W /
Signature of Certified Well Co pare
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the*welt(s)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 welh ❑Yes or E No copy of this record has been provided to the well ownm
f this is a repair,fill out kvowm well construction information and explain the nature of the
repair raider t21 remarks section or on the back of thisfornr. 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 muhiple tryection or non-water srtpply wells ONLY with the same consintetian,you can
submit oneforrr. SUBMITTAL 1NSTUCfIONS
2 .1�
9.Total well depth below land surface: J ._) (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdierent(ecample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: LQO VL) Division of Water Resources,Information Processing Unit,
#'water level is above casing,rise"�" _t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. s (in.) 24b.For Infection Well 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 24a
to the following: j
(i.e.auger,rotary,cable,direct push etc.) G
Division of Water Resources,jUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
i !
13a.Yield(gpm) Method of test: Alr 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136 Disinfection type HTH Amount well construction to the county health department of the county where
constructed. I!
Farm GW-1 North Carolina Department of Environment mid Natural Resources—Division of Water Resources Revised August 2013