GW1-2021-08063_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD i For internal use ONLY:
This front can be used for single or multiple wells
i
1.Well Contractor Information:
Chris King a4.M"9*Z0NEs . .
FROM TO I DESCRIMON
Vlrell Contractor Name It. 2
3415 IL It,
i
NC Well Contractor Certification Number __0UnR GeL�ING.for riulhrased.*dV':OR L NER'rfa' lieab7ej:•
Green River Well &Pump °�' rt TO ft. DtaMIETER m. relclavFss nuTeRtnL
Company Name 1C MER'CASINGURTUBllVG tkeima[lased-lao
FROM TO DLA111 ER THICKNESS BATE111M
2.Well Construction Permit#: -i 'C() 10 3 1 ja R. © ft g in. 21 PVC
List all applicable hell permits r e.Cmotty,State,lrarfance,injection,etc.)
ft ft. in.
3_Well Use(check well rise):
Water Supply Welk FROM TO I DMAIETM I SLOTSIJ.E I THICKNESS I MATERIAL
❑Agricultural ❑Mtmicipal/Public 2 ft i-
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft m'
❑lndustriaYCommercial ❑Residential Water Supply(shared) a$rthROUT _ .
FROM TO MATERIAL EMPLACEMENT MOD&AMOUNT
❑ n ate 0 1L 20 rt 3alvete Mot&Pour
METHOD
Non-Water Supply Well:
❑Monitoring ❑Recovmy R rt
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 39 SAND/GRAVEL°PACK da' ble
[]Aquifer TO MATERIAL EMPLACEMENTMErHOD
;.
Aquifer Storage and Recovery ❑Salinity Barrier � �
❑Aquifer Test ❑Stormwater Drainage R ft.
❑Experimental Technology ❑Subsidence Control
MDRD:LIlYG> attacli additional sheets:i
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON(color,hmdness,wil/rock lype,graimsFu,ete`.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q R I " & 5
7 C ft
4.Date Well(s)Completed: L� We61D# 'J Lis ft IP 1413oxn%5AS
4,5 iL ifi4 SyV�i • R,G
Sa.Well Location: too
15MAU MAKEIN� � S f
Facility/Owner Name Facility ID#(ifapplicable) R ft
AtLEN - �R r nKz5
k. ft.
Physical Address,City,and Zip =2!_RE11fARKS!, —
Coumty Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: !(.;'`'`'i;`„{t i'JI`!"!7"0CL'3Jii4t7 uI+I,
(ifwell field,one laVlong is sofficiem)
22_Certification:
3 ss N ��� 3 �"7W /4— —Z1
faratuae of Certified\Yell C or pate
6.Is(are)the we11(s): ®Permanent or ❑Temporary By signing this joint.I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 i 9No copy ofthis record has been provided to the well owner.
1f this is a repair,fill out brown well construction information and explain the nature of the
repair tender#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 iron-water supply wells ONLY with the same construction,you can
subnett oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �t!] (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nulls list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (10 (ft) Division of Water Resti'nrces,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 24b.For Iniection 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: tc-Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wens:
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.
Form GW-1 North Carolina Department of Ensironment and Natural Resources—Division of Water Resources Revised August 2013