GW1-2021-08078_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD "
For iutemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chas King FROM fr.RZO1VlsS T ,
FROM TO DESQHPf10N
Well Contractor Name It. fL
3415 fL fL
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NC Well Contractor Certification Number
15`o> reRrcAsnvc :oRrnR .=;.:
FROM To DIAMETER THIL"ESS MATERIAL
Green River Well&Pump ft. ft: in.
Company Name 16At NEK CASflVG.OR.TUBING'�' tbeimsl closed too`
Zbi��x EROM TO DIAMETER TIUCKNESS MATERIAL
2.Well Construction Permit#: 0611 i 1 b fL Zil, fL 6 in 21 PVC
List all applicable well permits(Ze.Cormh;State,Variance,b jection,etc.)
f1. 1t. in
3.Well Use(check well use): 37�SCR>IF3uT .._
Water Supply Well: FROM I TO I ommE7ER I sLOTsIZE I THtCKNffi MATERIAL '
❑Agricultural ❑Municipal/%blic fL fL hL
❑Geothermal(HeatingfCooling Supply) InResidential Water Supply(single) fL & In.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,4S:GROUT „
FRONT TO ` bATERIAL Ea1iPLACEMENT METROD&AMOUNT
Non-Water Supply Well: S
❑ lion 0 & 20 Salvete Mbc&Pour
❑Monitoring - ❑Recovery it. fL
Injection Well: & &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND1GRAVF PACK'der"`'" e,
FROM I TO I MATERIAL I EMPLACEIITENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft.
❑Aquifer Test ❑Stormwater-Drainageft R
❑Experimental Technology ❑Subsidence Control
20.DR1LLIlYc:1Mt 11tech' dif' ;3leetslr
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON mkr,hmdms%-W—k type,ena s�etc-)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0
4.Date Weil(s)Completed: 1t 2 1 ZJ Well ID# `7 ft, -
S
fL
Sa Well LoeaGon/:y Z5' ft- 30 J fL -
ON 117 Lr a l iaS & fL
Facility/Owner Name Facility]D#(if applicable)
r ft. &
ED q-, D
Physical Address,City,and Zip
2L`'REl1tARRCS. ,
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minotes/seconds or decimal degrees: 22 Certification "
(Dwell field,one Wong is sufficient)
3T 2-33 N W �A
Signature ofCertified Well Co or Date
6.Is(are)the well(s): OPermanent or []Temporary By signing this o I here certify that the wells was
$n g form, b3' fY () (were)conrtntded in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy ofthis record has been provided to the well owner
if this is a repair,fill out known well construction information and explain the nahrre of the
repair under 411 remarks section or on lire back ofthis.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,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: t
p (fr.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) construction to the following:
L I
10.Static water level below top of casing: 1 0 (ft.) Division of Water Resources,Information Processing Unit,
jwater level is above casing,use"�" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: s (in) 24b.For Injection 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.augger,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) 14 Method of test: Air 24c•For Water Suppiy&Injection Wells:
Also submit one copy of this fonts within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county h th department of the county where
constructed.
Farm GW-1 North Carolina Department of Emirormrent and Natural Resources-Division of Water Resources Revised August 2013