GW1-2021-08101_Well Construction - GW1_20211105

WELL CONSTRUCTION CORD
y For Internal Use ONLY:
Thus form can be used for single or multiple wells
1.Well Contractor Information:
Chris 1(ing :la va x'7.ONEs
FROM TO DESCRIPTION
Well Contractor Name ft. ft-
3415 R R
NC Well Contractor Certification Number 1I1TER CASING,{fbr mtdfred;wells.OR LII�R'der bIE
FROM TO DIAMETER THIL7QHFSS MATERIAL
Green River Well $Pump R R
,.
Company Name /y rItii:I>•iN1xRCAS1IVG�OR'TUBWG tlbsed-!oo .:_
Z 18 FROM TO DMAIEfER THICKNESS MATERIAL
2.Well Construction Permit#: t fL I R 6 i° 21 PVC
List all applicable well permits f.e.Catrtty,Slate,Variance,Iryedion,etc.)
It R in.
3.Well Use(check well use): 17iSC12EE1V,,...`: ,
Water Supply Well: FROM TO DIM1ETIIt SLOTSIZE THICKNESS r11ATERUL
❑Agricultural ❑Municipal/Public & R in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R R is
❑Industriil/Commercial ❑Residential Water Supply(shared) -1&,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ n Lion 0 R 20 ft. SalQete Mac$Pour
Non-Water Supply Well: iL ft
❑Monitoring ❑Recovery
Injection Well: R fL
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SA14D/CRAYI L P.ACK rf a licatile.,.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIACEalEP17 METHOD
R R
❑Aquifer Test ❑Stonnwater Drainage R R
❑Experimental Technology ❑Subsidence Control
s;2QDIt1LY.1NC;'ii(;NC'iittsietiadtli6unfilslreetsif:` -= '_
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(robr,rmdnes,aoiiheek �e Nr
❑Geothermal(Heating/CoolingL�Return) ❑Other(explain under#21 Remarks)
O R , fL
RED (I am 1 !+/ 21 4.Date Well(s)Completed: Well ID# 15- R SO R SANN C LAVI
b R Q R �� �A
5a.Well Location: R R ri
G�1 Mr�GRAW 5 R 3a5 R 61 Iry a<.
Facilitty//O�w,neerName Facility WO(ifaWlimblo) R ft.
�luf v F-4 S JCK.Lf- LN
ft. R
Physical Address,City,and Zip
E REMARKS. ._
5Lk� OV _
Counb' Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifit It
W
Signature of Certified Well Contract pate
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A 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 ONo 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 ti21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
p You may use the back of this page Ito provide additional well site details or well
&Number of we0s constructed: 1 construction details. You may also attach additional pages if necessary.
For muhiple n9ec'tfon or tan-water supply wells ONLY with the saran eorrsiructron,voeu can
suubmitoneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3®� (ft) 24ut. For All Webs: Subunit this form within 30 days of completion of well
For multiple wells list all depths iilA ferema(emmple_3@200'and 22/@��100') construction to the following:
10.Static water level below top of casing: (AV (R) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rue"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 246.For Iniectiou 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:
(ie.augur rotary,cable,direct push,etc.)
Division of Wateir Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L4 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forts within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county health department of the county where
constructed.
Foam GW-1 North Carolina Department of Err iromrent and Natural Resources—Division of Water Resources Revised August 2013