GW1-2021-08070_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD Forlatemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King
FROM TO -`DESCRIMON
WellCormactorName & &
3415 & ft.
NC Well ContiauorCerUficatmaNumber NFROA1
t3E1Z GASINC'tur:u ulReasell`' OItfi3T�R°Ufa'
TO DWIETF.R 1HICKNM MATERIAL4`
Garen River Well$Pump ft: ft in.
Company Name aIt'4G`OR T1tB1NG "iitbermil seed too'`
TO DIAMETER THICKNISS MATERIAL
2,Well Construction Permit#: 2-0 1 2(�, l 13 �2 Z ft. ft 6 21 PVC
List all applicable well permits(Le-Cd-4%Stoic Yarimrce,l4ectia etc)
& ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO 1 DMAWrEtt SLOTSIZE THICKNESS MATERIAL ^
❑Agricultural ❑Mumicipal/Public ti (L in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) (L & rn
❑Industrial/Commercial ❑Residential Water Supply(shared) :1ILCROOT .
FROM TO - MATERIAL EAIPIACEMENTA1Emon&AMOUNT
Non-Water Supply Well: U R 20 IL Salrete Mot&Pour
ft ft
❑Monitoring ❑Recovery
Injection Well: & &
❑Aquifer Recharge ❑Groundwater Remediation 39 SAiVD/GRAr£1 PAGE d a Gcmbie
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. Ft. ARTERIALI EMP1ACEMEhTMEMOD
❑Aquifer Test ❑Stormwate:rDrainage ft fL
❑Experimental Technology ❑Subsidence Control
{2DL:DRiI:tiIIVG;iOG:attaeti additioil�`13heeti'�'
❑Ge:otherinal(Closed Loop) ❑Tracer FROM TO DESCRIMON(color,hanhus&soil/mck si-etc)
❑Geothermal(Heating/Cooling Return) ❑Othe:r(explain under#21 Remarks) (0 ft. V/e fe t;
ft.
-7 �
4.Date Well(s)Completed: Well ID#
59.Well Location.
_ i � r {► ft. /tt
V(`)1� U IyV{N l , L &
Facility/Owner Name Facility B39(if applicable) ft. It
s
10;, fiL1 GA-PPS n ft f
Physical Address,City,and Zip 21 R£iYTARiZS
I-��VO €�Sa�ry NOV _ 5
County Parcel IdemificationNo.(PIIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Certifi
(ifwell field,one[at/long is sufficient) 22.
'� 1 J 9 N O L Z q LA W
Si6f6tre of Certified Well Contracto Daze
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 he c " �,h., e nell(s)was(were)conrtnrcted in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing welk ❑Yes or ®No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair tinder 421 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 multiple injection or non-water supply wells ONLY with the same construction,yvu can
submit oneform ii SUBMITTAL INSTUCCIONS
9.Total well depth below land surface: 1 (fL) 24a. For AD Wells- Submit this form within 30 days of complexion of well
For multiple wells list all depths ifdifferent(example-3 a@20/0'annd-�2@1001) construction to the following
10.Static water level below top of casing: Cn U (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. s (in.) 24b.For Iniection Wells ONLY:j 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 vvell
12.Well construction method: 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
1
13a.Yield(gpm) 3 d Method of test: AJ r 24c 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 county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
i