GW1-2021-08081_Well Construction - GW1_20211105

S
WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can he used far single or multiple wells
1.Well Contractor information:
Chris iQn9 .14.\VATER ZONES
FRONT TO DESCRIPTION
Well Contractor Name ft R
3415 Ft ft.
NG Well Contactor Certification Number I5.OLr1 ER'CASING(for multi cased wells)OR LL\ER if a lieable}
FR01t TO D1..01ETER THICiu'�'FSSI MATERIAL
Green River Well& Pump ft. ft. in.
Company Name 16.INNER CASING OR TUBING(!eothermal closed-too )
2.Well Construction Permit N: 10 IL O 10�6'0 Ia FRONT TO DIAMETER THICKNESS NLATERAL
Q � ft rt 6 'n- 21 PVC
List all applicable Hell permits(i.e.CounlR State,Variance,Injection,etc j
ft. it. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FRONT TO DLMIIETER SLOT SIZE THICKNESS NI- ERLIL
ft. ft.
❑Agriculttnal ONIunicipal/Public
❑Geothermal(I-Ieating/Cooling Supply) FiResidential Hater Supply(single) R R re
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM{ TO MATERIAL EMPL4CE\IENT\9ETHOD&A',%1011Nr
❑Irrigation Non-Non-Water Supply Well: 0 ft 20 IL Sakrete Mot&Pour
❑Monitoring ❑Rceovcry it. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation '19.Si NID/GRAVEL PACK firs Hcable)
❑Aquifer Storage and Recovery FROM TO MATERIAL EMPLACEML,NTiEE HoD❑Salinity Barrier tt n
❑Aquiter Test ❑Stormwater Drainage
` ft ft
❑Experimental Technology ❑Subsidence Control
20.DRtLLLNG LOG(attach additional sheets ifneces )
❑Geothermal(Closed Loop) ❑Tracer FRONT TO DESCRIPTION(rotor,hardnrss,snill rktype.grain size,et!.)
❑Geothermal(Heat ingJCooling Return) ❑Other(explain under Q1 Remarks) V ft ft 56NN
i
J 7,t2et 3 ft. 2.0 ft. -
4.Date Well(s)Completed: l .,)! Well ID#
ft. � ft.
a. Well Location:
ft i O fL
ALD 1ENQE310pli AM ft. ft
Facility/Otincr Name
�/� q�FacilityID'(ifapplicable) fL ft
ft. ft.
a
Phpsieal address.City.and Zip 21.REMARKS
}���V7>�xtsaiN
County Parcel identification No.(PiN) 'i
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees-
22.Ccrtificatio
(iiff%vell field,one laZt/lonu it sufficient)
.arum of Certified Well Contract Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
By signing this fort,I hereby certffir that the tre11(4 it-as(were)constnrcted in accordance
with 15A NCAC 02C.0100 or 15A VCAL 02C.0200 Well Constrction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well otr•ner.
lfthis is a repair,Jill out Maim irell consinmction information and explain the nature ofthe
repair under=21 remarks section or on the back of dais form. 23.Site diagram or additional well details:
You may use the back of this pa_e Ito'provide additional well site details or well
8.Number of wells constructed: � construction details- You may also attach additional pages if necessary.
For muhiple injection or non-water supply trells 0AT I'trith the saute constnmetion,r'ou ear
strbmitonefann. SUBMITTAL INSTUCTiONS -
` a�
9.Total well depth below land surface: (ft.) 2 Fa. For All Wells: Submit this!form within 30 days of completion of well
For nmultipie welds list all clepos ifdijjerent(&r wple-3@200'and 2@100') construction to the following-
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifirater level is above casing,use" 1617 Flail Service Center,Raleigh,NC 2769 9-1 61 7
I
11.Borehole diameter. 6 (in.) 24b. For Iniection Wells ONLY: �In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method. fY construction to the following:
(i.e.auger.rotary,cable,direct push.etc.) !
Division of Water Resources,Underground Injection Control Program,
FOR RATER SUPPLY WELLS ONLY: 1636 Mail Senice Center,Raleigh,NC 276994636
_ i
I3a.Yield(gpm) '�O Method of test: Air 24c.For Water Supply x Injection444
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.
Font G\d-1 North Carolina Department of Fnironment and Nanrral Resources—Disision of Water Resources Revised August 2013