GW1-2021-08065_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For eternal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris I(ing FROM
FROM TO DESC. RIPTION
Well Contractor Name Ito& Z'B T
3415 & ft
NC Well Contactor Certification Numbers ODTER;G9SINIG for ninth casedwells'OR I IHER'tfa Ll'
FROM TO -I DIAMETER TelCfamss alATO AL
Green River Well 81 Pump ft. EL
CompamName '263114NF.RG/FStIVGORI'IlB1NG,
11 FROM TO DIAMETER THICKN6� MATERIAL
7-Well Construction Permit#: [ I��i I S 1 l ft B y R s 21 PVC
last all applicable rrell permits ft4 Cotmt}.State,Variance,Injection,etc) & �Y f iO is
3.Well Use(check well use): 1- SCRkEN .
Water Supply Well: FROM TO _ DLUIEM SLOTSIZE THICKNESS _ afA7'ERIAL
❑Agricultural ❑Mumicipal/Public IL IL in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R• R in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
01rrilion IAL.FROM TO MATER " EMPLACEMENT METHOD&AMOUNT Non-Water 0ater Supply Well: ft 20 & sawete Mix$Pouf
❑Monitoring ❑RecoveY D- &
Injection Well: & &
❑Aquifer Recharge ❑GroundwaterRemediation 19:SANDIGRAV'ELPAC)£da oolicablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPIACEMENrMErHOD
❑Aquifer Test ❑Stormwater Drainage &❑Experimental Technology []Subsidence Control
;20.DRILLING-LOC attacliadditional'sheibif
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(mler,hmdnes soWnxk tym grATin sae,etc.)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) b ft 2ci &
& R
4.Date Well(s)Completed: 2o2Wen ID#
5a.Well Location:
ft- ft-
& &
/�
�L�W 1�111�iFrihl �
F`aacility/Owner Name �{• f Facility ID#(if applicable)
ft fL
Physical Address.City,and Zip 215iREMARKS,,;,
County Parcel Identification No.(P1N)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IaU 22.Certification'
lang is sufficient)
35 N On 35 JAJ W
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary by signing this form,I hereby terrify that the well(s)was 6rere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeR Construction Sram kr&and that a
7.Is this a repair to an existing we1L• ❑Yes or EINo copy of this record has been provided to the null owner.
ythis is a repair,fill out brown well construction information and explain the nature of the
repair tinder 021 remarks section or on the back of thisform. 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 non-water supply wells ONLY with the same construction,you can
submitoneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: JV s, 00 24a. For AD Wells: -Submit this form within 30 days of completion of well
For multiple ue0s list all depths ifdifferent(example-3 t@200'and 2@1001) construction to the'following:
IQ Static water level below top of casing: 5Q (ft) Division of Water Resources,Information Processing Unit,
If trater kiwi is abore casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11_Borehole diameter. s (in.) 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 avell
12.Well construction method: Rotary construction to the following:
lie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Vnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24e.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 country Where
constructed_
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Reused August 2013