GW1-2021-08072_Well Construction - GW1_20211105

'WELL CONSTRUCTION RECORD For lateral Use ONLY:
This farm can be used for single or multiple wells
L Wen Contraetar Inforremadoc•
9 : O ATER>TTO 'Dr�uPnON
Chris_Kln FROM
Wcu Contactor Name fL ft
3415 & ft
NC Well Contractor certification Number iSzODTER GASlNG. ORLIIniLR`'da 7
77
FROM TO DUMEM I 7HICIZNM I MATUML
Green River Well &Pump n. &
Company Name 6 N1H$ttGlsltYGOR 7 tISINU t
r
FROM TO DIAMETER THICKNESS MATffFJAL .:
2.Well Construction Permit# i 00 0 10 Z 5 & 6 'a 21 PVC
List all applicable well permits(Le_Cotmly.State,Yariarme,I*dim%etc.)
n ft in,
3.Well Use(check well use):
Water Supply Well: FROM TO.:: ,.T DMKET R SLOTSIM-. THICKNESS
❑ RIATERIAL� <,
❑Agricultural Municipal/Public ft m
❑Geothermal(Heating)Cooling Supply) aResidential Water Supply(single) R & m
❑wusbiwcommetcial ❑Residential Water Supply(shared)
FROM I TO I MATERIAL EMPLACEMHNf MErHOD&AMOt1Nr
Olffigation
Non-Water Supply well: 0 �' 20 Salvete Mix$Pour
❑Monitoring ❑Recovery,
Injection Welt R• &
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGlt&VEL•PACK. a bte . " '
FROM TO MATERIAL EMPIAC12tHYrMLMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquihx Test ❑Stormwater Drainage tt ft
❑Experimental Technology ❑Subsidence Control
20.=11RIIi`LYNG;YOG idhiehadditioiilslieetiif"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRe'rtON eolo,budmss,sm7hor4...` �., etc.
❑Geothermal(Heating/Cooling Return)' ❑Other(explain under#21 Reanarks) 0 fL 0 f
4.Date Well(s)Completed: —2 L Well im •0 fL 40 fL V
p n ivU ft Rc C -k
toO Sa.Well Location: ft- t�it _
L 61A&A ft ft ft.
Facility/OwnerName Facility ID#(ifapph=bh) & ft
l 3 Z GAF-SIN VI G;R IRD. R fL
Physical Address,City,and Zip i21Y'REMARK9':
l�r'�►��f�SoiN
County Parcel IdenifitationNo.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Ce 'on
(ifweR field,one lat%ns is sufficient) f�
SS V 1 b N 9Z 2y 3q W -2-2
Si of Certifi ell Date6 Is(are)the well(s� ®Permanent or ❑Temporary
By sigrring this form,r he certify that the wd!(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeA Construction stand_V&aad that o
7.is this a repair to an existing well: ❑Yes or. EINo copy ofdus record has been provided to Bee wet!owner
f this is a repair,frA out blown well construction information and explain the nature of the
repair miler#21 remarks section or an Be 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: I construction details. You may also attach additional pages if necessary.
For multple hijection or non-water supply wells ONLY with the same combaedi n,you can
submit one form I— SUBMITTAL INSTUCTIONS
9.Total well depth below fend surface: Z5 (fL) 24a For Aft Weis: Submit this form within 30 days of completion of well
For muhiple weQs tat aAdepda if dif/'erent(—ple-3@200•and 2@100) construction to the following:
It Static water level below top of casing 3 Q ((t•) Division of Water Resources,Information Processing Unit,
rfwater level is above casing use^+^ 1617 Mail Service Center,Raleigh,NC 2769SL1617
11.Borehole diameter. 6 011.) 24b,For Infection 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: Rotary construction to the following:
(i.e-roger runty,cable,direct push,etc-) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
f
13a.Yield(gpm) 0 Method of test Air 24a For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
HTH well construction to the county lieahh department of the county where
136 Disinfection type Amount constructed
Font OW-1 North Carolina Department of Fmironment and Natural Resources—Division of Water.Resomoes Revised August 2013