GW1-2021-08077_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For tnte>m1 Use ONLY: V
This form can be used for single or multiple wells
1.Well Contractor Information: - -
Chris I(ing4 WATt3tt'ZONS.Rs? �. .,
FROM TO ....DffiB119r V J
WellCoutractorNante R ft
3415 R R
NC WdlCmtnactorCatificatioaNamber
1 _out >tcesn�c. nit :'
FROM 'M DMINFrER TWCKNESS MATMAL
Green River Well & Pump R R
Colu>pauyName �tti`11VNnItCASIIVDAR<7'UBWG
!Y
7 i FROM TO DIAM UM THICKNESS _ MATERIAL
7-Wen Construction Permit#: ,zo I co �2 i-6 C( ` R R 6 1 in. 21 PVC
Lst art applicable well penniu(Le.County,state.Yarran¢e Lyec ion,etc)
R R is
3.Well Use(cheek well use): 17 B(12SEN .5
Water supply Well: FROM TO DiAm rmit sI. rsm THx3auss ia>ATBweL
❑Agricdkazl ❑MunicipaUPublic R R isL'
❑Geothermal(Heating/CoolingSupply) ElResidential Water SuPP1Y(s e) R R m
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM I TO MATERIAL IM11ACEMIMMMI37HOD&AMOUNT
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❑lrrr on 0 R 20 R Saltrete Mix&Pour
NOD-Water Supply Well: R R
❑Monitoring ❑Recovery
Injection Welk R R
❑Aquifer Recharge ❑GroundwaterRemedishon zi9 5i1PID/CRei! PACB sf' ?u x.x:?i k
FROM TO MATERIAL I EMPtACEMVffMETMOD`
❑Aquifer Storage and Recovery ❑Salinity Barrier R R
❑Aquifer Test ❑StormwaterDrainage R R
❑Fxperimealal Technology ❑Subsidence Control
r`20c;DR;I1:iAVGAOG .a'Leelsi€„ -
❑Geothemal(Closed Loop) ❑Tracer FROM TO DXSCRE14ON eelsr, saYmek m etc-) ~
❑Geothermal(Heating(Cooling Return) ❑Other explain under#21 Remarks) Q R R
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4.Date Wen �e/(s)Completed: /}v �' We111D# O RA R
R 5-Z. IL 'V)— E
5a.Well Location: R R
J OVA RI-C,E, R R
Facility/OwaaName � Facility ID#(ifapplicable) R R
)PMA M/t (J,e�D R R
Physical Address�City,and Zip
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County t?mcelldemitirarw ionNo.(PIN) - e
5b.Latitude and Longitude in degrees/mioatalseconds or decimal degrees:
Z:
(ifwell Sell one Iatilong is sufficient) 22.
-3S o3 +�z NZ 2� 17 w t . 2Z. 2
afCatified Well C—aad- Doe
6 Is(are)the welts) ®Permanent or ❑Temporary By sWft this farm I hereby certify that the well(s)was(were)oonarnwed a,aecrndmece
with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Constrixtioun Ards and flint a
7.is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to flu well owner.
If this is a repair,fill out known well construction h formotiion and explain the ratan of the
repair under#21 ramaris section or an the bark of thisfmm. 23.Site diagram or additional well details:
You may use the bark of this page to provide additional well site details or well
S.Number of wdls constructed: construction details. You may also attach additional pages if necessary.
For multiple Wectian or non-water sup*wells ONLPwith the same eassbucilan,you can
submit wit form. SUBMCITAL INSTUCTIONS
A Total well depth below land surface:_ Z `J (fL) 24a. For All Wills Submit this form within 30 days of completion of well
For multiple wells list all depths if (-ample-3(a)200'and 2@1001 construction to the following:
lk Static water level below top of using: 7-0 00 Division of Water Resources,Information Processing Unfit,
If water level is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11_Borehole diameter. 6 (in) 24b.For Injection Wells ONLY:l 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:
(ia sager rotary,cable,direct posh,etc-)
Div...of Water Resources,[Underground InjecdoD Coatrvl Program,
FOR WATER SUPPLYyWELIS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
Us.Yield(gpm) (ice Method of test: Air 24c.For Water Supply&Injection wells:
Also submit one copy of this form;within 30 days of completion of
13L DisWeetion type_ HTH Amount well construction to the County health department of the county where
mod_
Fomn GW-1 North Carolina DepmYnnent of EnvisamneM and Natural Resou ces-Ihvisim of Waiter Resomas Revised August 2013