GW1-2021-08091_Well Construction - GW1_20211105

WELL CONST_RMTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King .aa.warER=zox>s
FRObt TO DESCRIPTION
Well Contractor Name 3 0OfL 3©9
3415 ft. ft
NC Well Contractor Certification Number i5;OUTER GASII�TG.(fo>' itilti cased wells OR-LMR if a 61e
FROM TO DWIETLR TMCKNESS MATERIAL
Green River Well&Pump ft fL
Company Name 16ANNERCA's- GORTI)BING "kotti m'stdosed-ioo
Zo n FROM TO DIAMETER TH1c"Ess MATERIAL
2.Well Construction Permit#: (�J 3 a .. fe fL g in. 21 PVC
List all applicable well permits r e.County,State,Irariarrce,Injection,eta) in.
Well Use(check well use): 17:.SCRFL '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICA,'VFSS MATERIAL
ft
❑Agricultural ❑ UPu Mtmicipablic ft. in
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) R & 1D
❑Ind ustrial/Commerciai ❑Residential Water Supply(shared) 18 GROAT,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Waate ,
❑Reel ter Supply Well: 0 ft 20 fL Salvete Mot&Pour
❑Monitoring ❑Recovery IL ft.
Injection Well: ft. ft:
❑Aquifer Recharge ❑GroundwaterRemediabon ;19 SAPTD/GRAVELPAGg da' livable
TO
L7Aquifer Storage and Recovery ❑Salinity Barrier FROM fL ft MATERIAL EMPtACEMEN]"MEIAOD
❑Aquifer Test ❑StormwaterDrainage fL &
❑Experimental Technology ❑Subsidence Control
0idditioi ilsheets if
❑Geothermal(Closed Loop) ❑Tracer 20;DRIILIN_C:I UC
FROM To ➢ESCRIMON(color,hardness,.%6Vnxk size,etc
• ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) d 0 J e�
4.Date Well(s)Completed: � 3 Z 1Weil ID# f
Sa.Well Location: 0 ft fL GRF E
`�pw In R�f,�-t�T�fl �t cal ��L�S'i t � 3 Z Sf -;
ft ft
Facility/Owner Name Facility IDk(if apph-ble)
PPL-g �l Ra. ft ft.
Physical Address,City.and Zip
Count}, Parcel identification No.(PiN)
5b.LRtitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.73oo
eati
ZLi O2 N 8`Z, L 5 2 W 1f:j-Z
Signature ofCertified W Date
6.is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certijy that the well(s)was(were)constructed in accordance
with RSA NCAC 02C.0100 or RSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair M an esisfmg welh ❑Yes or allo copy ofthris record has been provided to the wail owner.
Ifthis is a repair,fill out known well construction information and esplatn the nature ofthe
repair render;U)1 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
&Number of wells constructed: f construction details. You may also attach additional pages if necessary.
For multiple injection or non-water surpply wells ONLY with the same construction,)'on can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 37-, (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(sample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: Z� 00 Division of Water Resources,Information Processing Unit,
Ijwoter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (iu) 246.For Infection Wells ONLY.1,In addition to sending the farm to the address in
24a above, also submit a copy of;this form within 30 days of completion of well
It Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable.direct ousk etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-106
139-Yield(gpm) Method of test: Air 24e.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'lth department of the county where
constructed. I!
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water R i esources Revised August 2013