GW1-2021-08090_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King A~Mt' 3
FROM TO DESCRIPTION
Well Contractor Name ft. ft
3415 ft. It.
i
NC Well Contractor Certification Number 1S:OU3ER CASING formultr cased we1Ls OR'Is1PiER:rf"' Ircable ; ,
FROM TO DIAMETER THICKNESS MATERIAL
Green River Well & Pump ft ft. im
Company Name N6.INNER CASING ORS USING 'eothermsticlused�oo
O R ` o O r FROM TO DIAMETER THICKNESS MATERIAL
V 2.Well Construction Permit#: ` b ft- ft- 6 'g 21 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑lndustriallCommercial ❑Residential Water Supply(shared)
FROM TO MATERIAL x EMPLACEMENT METHOD&AMOUNT.
❑hTi ation 0 rt 20 rt Sakrete Mix&Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery it ft Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Remediation ; 9.SAND/GRA EL 'AC-W if i 'liabk ;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
It. ft
❑Aquifer Test ❑Stormwater Drainage fL
❑Experimental Technology []Subsidence Control
.20:;pR1I3:ING;Ti�G at`tactiradddidnal=slteetsifaecessa a�_ _ -'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitf o k type,i rain sire,etc_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R ft
R ft
4.Date Well(s)Completed: ~ 1 Well 1D# O ft �0 ft.
5a.Well Location: fc eft
elk"11,111;E1 pO ,� � TC�t.� y
ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
zl'] AV PI.� � -,��1 . ft. ft
Physical Address,City,and Zip
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22• ti �U._ 5(ifwell field,one IaUlo sufficient)is succiient) �j L , L/
J J� -iLi 2J N 1`/Z Z 1 LA ' W
Si(,mature of Certified Well Contrac Date
6.Is(are)the well(s): GOPerroanent or ❑Temporary by signing this form,I hereby celrrify that the well(s)was(were)constructed in accordance
with I SA 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 fflNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks 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
8.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 INSTUCTIONS
9.Total well depth below land surface: C�� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multole wells list all depths if tli erent(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
'i
13a.Yield(gpm) 10 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 health:department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013