GW1-2021-08087_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For lmemal Use ONLY:
This form can he used for single or multiple wells
1.Well.Contractor Information:
Chris King 1VWATER•Z INJFS
FROM I~DESCRIPRON
Well Coramarxor Name R R
3415 fl. e.
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NC Well Contractor Certification Number ;.IS Oi)TER'CtYSING ui midtesed'.ireUs ORL•1NElt rf:_a ).
FROM TO DL&MI'TER -MICIZNM MATERIAL
Green River Well& Pump R R in.
Company Name 16,INNER:Gi1S1111G-0R'i'11BING &er'mslr'l oo"
FROM TO DIAMErElt THICKNESS AL4TERIAL
2,well Construction Permit#: ZO i cl it L4 ) -1 Q 7 It -1 5' R 6 run- 21 PVC
List all applicable well permits(L a Comm;State,van-we.injection,etc.)
R R in.
3.Well Use(check well use): 17sSCRE&N
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I TWCKNESS MATERMLL
❑Agricultural ❑Municipal/Public IL I R hn
❑Geothermal(Heating/Cooling Supply) TResidential Water Supply(single) fL fL in
❑Industrial/Commt rcial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUW
Non-Water Supply Well:
❑ lion 0 It. 20 fL Salvebe Mot&Pour
❑Monitoring pltceov h' FL
eY
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 1O;SANDIGRAVEL PACH'rfa''livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO tdA7ER1AL EMPIACEPIENTMETHOD
ft. R
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control R R
20 DRILIdNCIiOG attaebadditioriiit°sheets if
❑Geothermal(Closed loop) ❑Tmoer FROM
� TO DESCRIOMO1N((rn a rer,bdo�s.sm7treek saeete)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) v fL 30 R t',! -i 1-
4.Date Well(s)Completed:1 L"�2y Well ID# v R 72 R S11a/C
o ft (o0S'R GrC[rLr L
5a.Well Location:
R R
r
M I i<e L L i A iKt R R
Facility/Owner Name Facility IM(ifapplicable) R R
C AM2 R R -�
Pbysical Address,City,and Zip ^
21 REMAIUM
Nr IsDOLSON
l�
County Parcel identification No_(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(ifwell field,one Wong is sufficient)
.35 25o�z 23 N -�2.3 71627Z W i ZC z 0
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this fort,1 hereby certify the rrell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA AC 02C.0200;Well Construction Standards and that a
7.Is this a repair to an existing we1C ❑Yes or ElNo copy ofthis record has been prm4ded to the well owner.
ifthis is a repair,fill out brown well construction information and explain the nraure of die
repair under#21 remarks section or an(he back of thisfonn. 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCCIONS
9.Total well depth below land surface: V®S (ft.) 24a. For An Wells: Submit this Iforin within 30 days of completion of well
For multiple wells list all depths if different(example-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,
Ifwater level is above casing,use—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injection Well ONLY: in addition to sending the form to the address in
12 well construction method: Rotary24a above, also submit a copy of this form within 30 days of completion of WRII
construction to the following:
(Le.auger,rotary,cable,direct push,etc.
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection lWens:
HTH Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Amount: well construction to the county heaith department of the county where
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Rek ources Revised August 2013
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