GW1-2021-08069_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
'Ibis form can be used for single or multiple wells
1.Well Contractor Information:
Cl1nS King
FROM TO DESCRIPTION
Well Contractor Name R Iti
3415 ft. f>.
NC Well Contractor Certification Number 15`OTII R C;451NG for o nlfi cater."�eIIs OR=i�IIVElt'der "ble`
FRO ni To DIAMETER I MATERIAL
Green River Well &Pump ft. It. in.
Company Name :t6 INNER GAIN OR-,VOWNG.`eot�rmalt losed3oU`"
r FROM TO DIAMETER THICKNESS MATERIZI,
2.Well Construction Permit#: Z 2-O I I i O 1p l R IfIL
g in. 21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc-)
& in.
3.Well Use(check well use):
la SCREE,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERlAI
❑Agricultural ❑Mtmicipal/Public ft. It. to
❑Geothermal(HeatingtCooling Supply) OResidential Water Supply(sm(single) R IL m.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18 iGROt1T
FROM TO� MATERIAL EMPLACEMENTMETROD&AMOUNT
OfiTigation
Non-Water Supply Well: O ft 20 R Sate Mix&Pour
FL &
❑Monitoring ❑Recovery
Injection Well: R 8.
❑Aquifer Recharge ❑Groundwater Remediation ,40.SANDIGRAVEL PACI3 der r�cable
`
❑Aquifer Storage and Recovery ❑Salinity Barrier ft.FROM TO FLMATERIAL EMPIACEMEdTMETROD
❑Aquifer Test ❑Stormwater Drainage Fc
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed Loop) 110 DRUI NQ'LOGG.(attactiaddih'or►ilaheiis_if'
( P) ❑Tracer FROM I TO DESCRIPTION(color,hardness,soiFraektype,griln sra etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under421 Remarks) ft 10
& `
4.Date Well(s)Completed: Well 1Dt1 d f L O f Vr4 -
Sa.Well Location: ft (G C) f
to a ft —1 6 ft la'(a
L 1L%,11W (7 ft' aPr�V T
Facility! wner Name Facility ID#(if applicable)
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreWminutes/seconds or decimal degrees: 21 Certifrcatio `t!lir'"i'!`v�hl••��'' `'
(ifwell field,one Iablong is sufficient)
3� L1 N `L 23 og W � t v-2/
Si of Certified Well Contmct Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this foron.I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weth ❑Yes or RlNo croW of this record has been provided lathe well owner.
Ifthis is a repair,ffl out A sown well construction information and explain the nature of the
repair nmder 421 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
i You may use the back of this page to provide additional well site details or well
&Number of wells constructed: l 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: \ ' (ft.) 249. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenr(example-3@200'and 2@1007 construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
1f water level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY:I 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
11 Well construction method: Rotary construction to the following:
(i-e-eager,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) IQ Method of test: err 24c.For Water Supply&Injeeti n Wells:
Also submit one copy of this foml within 30 days of completion of
l lTH well construction to the county health department of the county where
13tL Disinfection type: Amount: �
constructed.
Forst GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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