GW1-2021-08080_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD
For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King 14.%VATER ZONES i
FROM TO I DESCRIPTION
Well Contractor Name ft. & I'
3415 fL ft f
NC Well Contractor Certification Number M OUTER CASING(for r multi-cased wells) LINER(if a liable
FROM TO DIAMETER THI R(i 1ATERIAL
Green River Well &Pump & ft I in.
Company Name ;16 INNER CASING OR TUBINGr dosedl000l
rt �� I ! FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ` ` ( ft 3 ft g in. 21 PVC
List all applicable well pemrits(i.e.Connn•,Stare,irariance,14ection,etc.)
ft ft. in.
3.Well Use(check well use): 37:SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNM MATERI"
OAgricultund ❑MunicipaMblic ft. k
in.
R f in-
❑Geothermal(Heating/Cooling Supply) KIResidential Water SuPP1Y(single)
❑Industrial/Commemial ❑Residential Water Supply(shared) 1&GROt1T
FROM TO MATERIAL EMPIACEMEW. E M MOD&AMOUNT
Non-Water Supply Well:
❑ Lion 0 ft 20 ft. Sakrete Moe 8,Pour❑Monitoring ❑Recovery R ft
Injection Well: & &
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVBL`PACK617A liiable
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStoratmater Drainage R
❑Experimental Technology ❑Subsidence Control ft
20.DRFLLING"LOG(attacti additionit!Aicts ifnecc n
❑Geothermal(Closed Loop) ❑Tracer FROM To DFscRmlloNleala,narawtss so;umekt sze ere.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) & fL CIN '
I(4.Date Well(s)Completed: � /��Well ID# ft ft� B �
a- r � iL
Sa.Well Location: � ,� � R
Ro► �Nc7 �R� �. AIN LEE,
ft ,:.
Facility/Owner Name Facility ID#(ifapplicable)
Zoy VANS. ft
tz T
Physical Address,City,and Zip 21.REMARKS
mew 9i
'IVY luzi
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Certifie 'on
(ifwell field,one IaUlong is sufficient) 22. 5
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35 15 i i N Q>2 31 05 W ,r � hp'L-
nature of Certified Well Contractor D e
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby h'that the well(s)ttes(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or EONo copy ofthis record has been provided to the yell owner.
If this is a repair,fill out brown well construction it forrrratimr and explain the nantre of the
repair under'2I remarks section or on tire back of this form. 23.Site diagram or additional well details:
You may use the back:of this pagelto 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 oneform. SUBMITTAL INSTUCTIONS -
9.Total well depth below land surface: 1 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent('example-3@20 'and 2@I00') construction to the'fallo%% ing:
10.Static water level below top of casing: jA D (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6 (in.) 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.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUndergroand injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Z. Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fonts within 30 days of completion of
13b.Disinfection type: HTH Amount: %yell construction to the county heldth department of the county where
constructed-
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013