GW1-2021-08084_Well Construction - GW1_20211105

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WELL CONSTRUCT�N RECORD For internal use ONLY:
Wits form can be mei f--, : tiple ells
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1.Well Contractor Informatio
Chris Kin gI4 WATI�ItZONLSS _ r
FROM TO DESCRIMON
WellCmaa zcrName $sfL `B R O
3415 FL R
\C Well Cotr .orCenifiption Number
I5:-UTER CASING fii.ma14 mcea'welts OR LITTER.ha ble'- .
17t011 TO DIAMETER 1HICKNESS MATERIAL
Green River Well$Pump m It,
Compan.Name „-iiICZINNER'CASINGOIC`iURING"edtkermalelosedaoo`
q t aof j 3 �. FROM TO DIAMETER THICKNESS MATERIAL
?Well Construction Permit#: t fr d R 6 m 21 PVC
List all applicable well permits(ie.Cnmht State,Variance.Injection,etc.)
R. LL is
3.Well Use(check well use): 17r'SCREFdT =s _
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal(Public ft. M to
❑Geothermal(Heating/Cooling Supply) 91Residential Water Supply(single) R R in.
❑industrial/Commercial ❑Residential Water Supply(shared) '18 CBOtf1 ,-
FROM TO µ MATERIAL EMPIACEMENPMETHOD&AMOUNT
0krigation Water Supply Well: 0 ft20 fL Salmet Mix&Pour
Non- FL f
❑Monitoring ❑Recovery
Injection We1L• R R
❑Aquifer Recharge ❑Groundwater Remediation 19"SANDIGRAVEL,PACK'ds'l"ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEDTENT 11IErROD
tL rL
❑Aquifer Test ❑StormaaterDtaimage R R
❑Experimental Technology ❑Subsidence Control
30 DRFLTWG LOG atticli additkital sbeei3'ff uectssa "s
❑Geothermal(Closed Loop) ❑Trager FROM TO DESCRIPTIONtcotor,Iuu ns%so8hock simete.)"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q n• S ft RE
R R j,
4.Date Well(s)Completed: ?. Well ID# S w _ L
5a.Well Location:
Lyrt�an] 1-IUcr ft. j�� it.
Facility/0%maName Fac7ityW9(ifapplicable) ft R
Physical Address.City,and Zip 31ltBDLAItItS k a + i':
-
Cotmty Parcel identification No.(PIN) _ 2021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certi i lion i
(ifwell field,one lat/long is suffrcierd)
Signature of Certified Welt Contractor Date
6.Is(are)the w•ell(s): ®Permanent or OTemporary
By signing this form.1 hereby certify Idte wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well• ❑Yes or allo copy ofthn record has been prowded to the well owner.
If this is a repair•ftAout brown well construction information and a Thun the nature of the
repair ender 1R21 ream section or on the 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 mrdhple injection or non-water supply wells ONLY with the same con on you can
submit ane form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: 8 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erample-3 aQ200'and
�2Qa 100) construction to the following:
10.Static water level below top of casing: 40 00 DivIS10D of Water Resources,Informatlon Processing Unit,
lfwater level is abore casing,tine"+" 1617 Mail Service Center,Raleigh,NC 276WI617
11.Borehole diameter, 6 (In) 24b.For Infection Wells ONLY: In addition to sending the fort to the address in
24a above,also submit a copy of ithis form vdthin 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger.rotary,cable,direct push,
Division of W ater Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 10 Method of test: err 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 bt alth department of the county where
constructed.
FormGW-I North Carolina Department of Environmern and Natural Resources-Division of Water ltesou cm Revised August 2013