GW1-2021-08068_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Intern(Use ONLY:
'this form can be used for single or multiple wells
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1.Well Contractor Inrormation:
CF1nS King FROM TO I DESCRIPTION
Well Contractor Name ft ft
3415 ft. ft
NC Well Contractor Certification Number I5`ODI�R'_CASINC for'meld cos d:Wells©RLIl�R rfi b1E
FROM 7D DIAMETER I THICKNESS MATERIAL =
Green River Well 81 Pump It fL in
Company Name Afi MNEWCUINGORTUBING eothermsl`elosedlon'
r 1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Cotistruction Permit#: G 1 �+ 1 �Li ft fa g is 21 PVC
List all applicable well permits r.e.Count};State,lrariance,hjection,etc)
fL fL in.
3.Well Use(check well use): .1aCRBEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public R. R' in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R R iv
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18 GROUf
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 0 it 20 fL Sakrete Mut 8t Pour
Non-Water Supply Well:
❑Monitoring ❑Recovea R ft
Injection Well: fL S.
❑Aquifer Recharge ❑Groundwater Remediation =19;%AND/GRAVEL PACH ff a ficable
FROM TO MATERIAL EMPLACE WNTMETHOD
❑Aquifer Storage and Recovery FROM Barrier ft. D
❑Aquifer Test ❑Stormwater Drainage ft. tz
❑Experimental Technology ❑Subsidence Control
:20:pR1LLIr,:AVG;IOG'attachpddttronlilslkefs fn �'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(eolor,hardness,saWnwk type,.grain sa,ae.
❑Geothernal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J O fL 2 ft vR"
4.Date Well(s)Completed: Well I IL D# c;> fL 0' F-
Sa.Well Location:
10 M R ft v'W
tt It
Facility/Owner Name Facility 0t1(if applicable)
5 i AVQL-e`i LW. ft fL
Physical Address,City,and Zip
�. D FRQa_
County Parcel Identification No-(PIN) ,
-5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat long is sufficient) 22.Certifica a:
35 t � Z% N 9)Z S?a 4 �i W %� 71, o 2 f
S' of Certified Well Cc Dare
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 allo ropy of this record has been prmdded to the well owner.
If this is a repair,fill out knower well construction information and explain the nature of the
repair tinder 421 remarks section or on the back of this fomL 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 injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 1, SUBMITTAL 1NSTUCfIONS
9.Total well depth below land surface: J ��� (fL) 24a. For AM Wells: Submit this form within 30 days of completion of well
For multiple wells list off depths ifdifferent(example-3�1a 300'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water letel is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY4 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:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
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
131L Disinfection type: HTH Amount, well construction to the county health department of the county where
constructed.
Form Get'-1 North Carolina Department of FJnironment and Natural Resources—Division of W ater Resources Revised August 2013