GW1-2021-08100_Well Construction - GW1_20211105

WELL C Ne�'T CTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information;
Chris King la H{ATEItzONlrs
FROM TO ..DFSCRIYRON
Well Contractor Name ft. ft
3415 & R
NC Wetl Contractor Certification Number 15t;OU TER CA37NG(foe molh-eiiid- dL4"ORI IlVER rt" e
FROM TO DIAMETER THICRA'FSS MATERIAL
Green River Well&Pump R. R in.
Company Name `&INNER CASING OR'1 t1OING_( clbse"oo''(
�� O FROM TO DMMETER THICKNESS MATERIAL
2.Well Construction Permit#: R rL 6 in, 21 PVC
List all applicable well permits G.e-Cozmry;State,Variance,byediom etc.) R R in.
3.Well Use(check well ase):
;17.'SGREEN.
Water Supply Well: FROM I TO •�I .DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaVPublic H• R iu.
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) R R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S GROt1T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUV. r
❑bTi tion 0 % 20 & sakrete Mac&Pour
Non-Water Supply Well: R R
❑Monitoring ❑Recovery
Injection Well: R R
❑Aquifer Recharge ❑Groundwater Remediation 19.`SA DlGRAYEL1AC Cif a L pbtjt le
EM
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL PIACEMENI'METRODR R
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
-10:DRIId:RVC.TOG Sttech'additioiiaLsheetsfncm ° - `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ON(color,batdness,soNroek typp ZrAm size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R R ! t'
Q R
4.Date Well(s)Completed: I l i! Z'Well lD# -'o R e
IL So.Well Location: t� tl '
Jn %\V J ( i'1�ri R ` �R c,
Facility/Owner Name Facility lDk(if applicable)
R R
d L1 I Nh,eS5 r fad;i" lm ft ft,
Physical Address,City,and Zip 21-RI Ik1ARKS It ', s"r
PMUL
County Parcel Identification No.(PIN) NOV - 021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati ;
(ifwell field,one lat/long is sufficient)
� o 21 30 N `) t J S W
Signature of Certified Well Contracto Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction Standards and that a
7.IS this a repair to an existing we1L ❑Yes or allo copy ofthis record has been provided to llte well owner.
If this is a repair,fill out knoer well construction information and explain the nature of the
repair under*21 remarks section or on the back of thisform. 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,yozi can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ''1 C (tit,) 24a. For AD Wells: Submit this,form within 30 days of completion of well
For nudliple wells list all depths ifdiQ"erent(example-3 00'aiind 2@100') construction to the following:
10.Static water level below top of casing: 1 L 0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is abore casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 0-) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
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 Mad Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 1 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.
A
Form GW-1 North Carolina Department of Ehnvomnent and Natural Resources-Division of Water Resources Revised August 2013
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