GW1-2021-08083_Well Construction - GW1_20211105

WELL CONSTRUCTION RE '^^"
Thu form can be used far single or multiple wells For Interval Use ONLY:
1.Well Contractor Information:
Chris King 14'li'ATEIttiO1VES _:< �5..
FROM Im .. .DESCRIPTION
Well Contractor Name & fL
3415 IL &
NC Well Contractor Certification Number ;15 UUTERCASIId(r'(far math ekedvr Og;1;IlVgR ha L7e`
FROM TO DIAMETER THICKNESS MATERIAL
Green River Well&Pump II_ &
Company Name 'MANNER'-- IN0`O1k;7`UB1NG` tturmiil Elosed=Y
r / FROM TO DIAM67ER TtllCI.N1SS MATERIAL
2.Well Construction Permit a. -.O 1 7-� 10 B IL g is 21 PVC
List all applicable well permits(r.e.Cmmot,,State,Variance,injection,etc.)
ft. R is
3.Well Use(cheek well use): ,_17SCREEN
Water Supply Well: FROM TO.? DIAMETER St OT SIZE I THICKNESS` MATERIAL
❑Agricultural ❑Mtnicipal/Public tt. D. in.
❑Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) IL & in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&,GROtlT
❑1rritIOR
FROM TO MATIA ERL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O & 20 ft Sakmf Mix&Pour
❑Monitoring ❑RecoverY ft &
Injection Well: & S
❑Aquifer Recharge ❑Groundwater Remediation "i9-SAND/WAVEVp_ACK ifa Bride
❑A uifer Storage FROM TO MATERIAL IIHPIACE,�tII�T q rage and Recovery ❑Salinity Barrier METHOD
ft ft.
❑Aquifer Test ❑Stormwater Drainage
R f!
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer ?2ti3=bR11,I3TtG;IiOG(attae>iadditigri3lsluets':t, :� ;.,
FROM To DESCRHrI•ION(cater hudaess,coal ' s?u,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) S. � ILS
4.Date Wed(s)Completed: 7 •ZI Well tm R f ; VMO
Sa.Well Location:
0 ft E
E � KkI OL(S o R o t
fL tL
Facility/Owner Name F-fury IDk(if applicable)
j �4 ft R
1 _ t�F�, C,R�1 fL
Physical Address,City,and Zip
21.<R£llfAftlS$,. t a.=.;•
! 7N n
County Parcel identification NO.(Pik) N O V
5b.Latitude and Longitude in degmes/minotes/seconds or decimal degrees:
ffi Certification(ifwell field,one lat/long is sufficient)
0 N Z 7 a - W
Iz
Si ofCertified Weil C Kor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 hereb},certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.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.
Ifthis is a repair,fill out,brown well construction information and explain the nature of the
repair tinder=21 remarks section or on fire 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: construction details. You may also attach additional pages if necessary.
For multiple n jection or non-water supply wells ONLPwith the same construe ion,you can
submit one farm SUBMITTAL MSTUCTIONS
9.Total well depth below land surface: tno (ft) 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffervW(example-3@200'[-d 2 a@100') construction to the following:
10.Static water level below top of casing: t/0 (ft.) Division of Water Resources,Information Processing Unit,
lfxuter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. s rm j 24b.For Infection Wells ONLY: !In addition to sendirm 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 h�mna Rotary construction to the following:
(Le
.mm-,rotary,cable,direct push,eM.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) `• Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county he th department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013