GW1-2021-08085_Well Construction - GW1_20211105

N.
NVELL CONSTRV' TIO RECORD - For Internal Use ONLY:
This s`a! :an be used for s le or r; _le well
1. tfi Contractor I are 'on.
Chris King Fs:,�rATERZo1vEs
FROM 70 DESCRIPTION
WeE r mractor Name ' 0 rtVb ft
3415 & ft
t Contractor Certification Number 15:0IITERGA8ING fariuol6-ciSed trolls"ORLINII2:rf a " Ble
FROM TO DIAMETER 7HT©OV'FSS mATERt4L
Green River Well & Pump &
zmpany Name 16,INNEIt:GAS1NG OR 7 UB1NG_"eotheimsl'clused too
R 1 Oo I � ^C.J FROM TO DIAMETER THICKNESS MATERIAL
Well Constriction Permit#: L�.j �! .1 ftlb!oit 6 tO 21 1 PVC
all applicable well permits(Le.Cmam;State,Varimice.Injection,etc.)
R ft m o gJ J 1 V
3.Well Use(check well use):
l7;SCREEN
;pater Supply Well: FROM I TO I DL"IE ER:.. SLOT SIZE THICKNESS...-. MATERIAL .
Agricultural ❑Mtmicipal/Public ft. ft
❑Geothermal(HeatinglCooling Supply) EIResidential Water SuPPI)(single) ft ft. to
❑lndustrial/Commercial ❑Residential Water Supply(shared) ati GROUT
FROM TO 4 MATERIAL EMPLACEMENT METHOD&AMOUNT
ElIrrigation
Non-Water Supply Well: 0 20 Salvele Mb(&Pour
ft ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 19SAlVDICRAYEI PACK rfa livable
FROM TO MATERIAL EMPLACUTFNTMUMOD
❑Aquifer Storage and Recover}-- ❑Salinity Barrier R R
❑Aquifer Test ❑StormwaterDrainage ft
❑Experimental Technology ❑Subsidence Control
20 DRII:LING I oG;attacR additiong sheets if aeces
❑Geothermal(Closed loop) ❑Tracer FROM TO DTSCRIPr'IONIrnMr.hardaess.suilhock type,Vain svt,r1c.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) & l ft n N
O v
1? �1 ft. L ft w!
4.Date Well(s)Completed: Z 7 Z Well ID# L -
J_f ftlog R
AAJr-
1
5a.Well Location:
9sTft eft i
Facility/011nerName {� Facility M#(ifapplirable)
ag�.nw r l/t ty, ft. ft
Physical Address.City,and Zip
21 REMARKS
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certif ation:
(if well field,one Iattlong is sufficient) �,. ( t'r"'' ({1 i10 Or-`3
,t.^'''
3t�5, Zvi y N z 33 13 W ow
.Si mature of Certified Well C or Date
6.IS(are)the well(s): ®Permanent or ❑Temporary By signing this form.I hereby certh,that the well(s)it-as(were)cvnstnreted in accordance
with 15A A'CAC 02C.0100 or 15A A'CAC 02C.0200 Well Consiniction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo cop.v of this record has been provided to the well owner.
Ifthis is a repair,fill out known well constniction information and explain the nature of the
repair under--21 remarks section or on tire 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
8.Number of wells constructed: construction details. You may also attach additional pages ifnecessary.
For imdtiple injection or non-water supple wells ONLY with the same construction,i ou can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24n. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdifferent(example-3 a@200'//mid IQ100') construction to the following:
10.Static water level below top of casing: tS:0 (ft.) Division of Water Resources,Information Processing Unit,
11frrater level is above casing,use"+" 1617 Mail Service C i enter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:I In addition to sending the form to the address in
24a above, also submit a copy of;this foam within 30 days of completion of Avell
12.Well constriction method: Rotary construction to the following:
(Le.auger,rotary.cable,direct push,etc_)
Division of Water ResourcesJUoderdround Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c� Air 24c For Water Supply&Injectio 4 Wells:
13a.Yield(gpm) J Method of test
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county hei ttl department of the county where
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
r