GW1-2021-08057_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information: r
Chris King 14:W"ERZl1N FSex
FROM I TO DESCRIMON
Well Conuactor Name 2-4 ft Z fL
3415 & IL
`15 OUTfkCASING' ORI1NElt it
NC Well Contractor Certification Number tor'mulfrai5ed
FROsi To DIAMETER in.
MATERIALGreen River Well&Pump ft. ft. in.
Company Name6 i"' 21 PVC
Ifx'IlV1 M CASING Off TUB1NG"'eotherms'li6ed-"
2.Well Construction Permit `
i 1 Zl�100 V TO DIAMETER TLICKNESS MATERIAL _
#: (0� rr. �
List all applicable wcll permits rt e.County,Srote.Variance Ir jection,etc.) r
& ft
FROM ro
3.Well Use(check well use):
Water Supply Well: FROM I To D An1ETER;:I SLOTSEM I MUCKNESS I MATERIAL
❑Agricultural ❑Municipal/Public & iL is
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) R & im
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMEI'NMLINOD&AMOUW.
Non-Water Supply Weill: la
❑Ii lion 0 20 fL SaeW Mix&Pour
❑Monitoring ORecovery R' ft
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19:Se11�DICRAVFI:PACI rfa 'Gieaitle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPIACE 1ENTMETROD
& tie
❑Aquifer Test ❑Stormwater Drainage
& ft
❑Experimental Technology ❑Subsidence Control
70.D1tII:1.INC 1MG:s ttiiili additioi flsitcets' `
❑Geothermal(Closed tmp) ❑Tracer FROM TO DESCRUMONfeubr.bwdnes%sm nwk m rain. sbe.etr
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ftI
ft fc
4.Dar Well(s)Completed: j� Well ID# � V— 4-SAND
Sa.Well Location: ft Q ft
FacilityJOwcer Name Facdiry MH(if applicable)
IIL ft
& rt. R NOV 5
Physical Address,City,and 72P
-
nrrn7i(IiID
County Parcel Identification No.(PIN) a•+ '.1, •1•
5b.Latitude and Longitude in degrees/minateskmands or decimal degrees: 22 Certi n
(ifwell field,one lat/long is sufficient) -
'3S I y0 N �� ZZ i W
Sigmnue ofCertified Well Contract p
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby unify that the weU(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 well• ❑Yes or ElNo copy of this record has been provided to the well owner.
P'this is a repair.full out hnown well construction information and explain the nature of the
repair under 921 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 m uli ple hyection or non-water supply wells ONLPwdth the saute a intraetian,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Lr 1p� (1t.) 24. For All Wells: Submit this form within 30 days of completion of well
For mmfliple wells list all depths ifdif'erent(esample-3@200 and 2@100 construction to the following:
10.Static water keel below top of casing: J (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. s (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
(Le.augur,rotary.cable,direct push,
Division of Water Resources,GUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f 2 Method of test Air 24c-For Water Supply&lojectio i Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type_ HTH Amount %veil construction to the county health department of the county where
constructed. I
Form GW-I North Carolina Department of Fmironment and Natural Resources-Division of Water Resources Revised August 2013