GW1-2021-08102_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Infortrtation:
Chris King
°l4J WATEA'7.ONEs
FROM TO J DESCRIPTLON
Well Contractor Name & It.
3415 & to
NC Well Contract or Certification Number 15.'OUTER:GASING formidtressed+weRc)Olt'IINE1t d _...
FROM TO DIAMETER THICKNESS MATER/AL
Green River Well$Pump rLEL
Company Name 1&'1IVLVEtt'CASlA1G Oit3el)BING, eottrsmsl'ctosed-lSi '
FROM TO DIAMETER THICKNESS (1]ATFRIAt. I
2.Well Construction Permit 9-_ Q► i -3 11 i tr M - 21 PVe
List all applicable well permits re.Count};State,Variance,Injection,etc)
ft. R. in.3.Well Use(check well use):
1�=StREFd�T .. _ •.
Water Supply Well: FROM To I DIAMETER SLOTSIZE TMQUYFSS I MA-MMAL
❑Agricultural ❑MunicipaMblic ft. & in
❑Geothermal(Heating/Cooling Supply) VIResidential Water Supply(single) & & in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '1&GitOUT
FROM TO u MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply We ll:
'
❑ lion 0 ft. 20 & Salve Mb(&Pour
o
❑Monitoring ❑RecoverY IL f6
Injection Well: ft &
❑Aquifer Recharge ❑GroundwaterRemediation 19rSAND"/GRAVEL'PAGK d'a livable
FROM TO MATERIAL EMP[ACEDiEtY'P DiETlt01) ..
❑Aquifer Storage and Recovery ❑Salinity Barrier IL ft
❑Aquifer Test ❑Storm-aater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
-•Zkv 1ATIG;IAG:attar 'additi6n51 sbeets"if
[]Geothermal(Closed Loop) ❑Tracer FROM To DESCRwnON(color,hmfv—,soilf—ktyM gimi.AM etc)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under921 Remarks) L t'
4.Date Well(s)Completed: �Z/�1 Well 1D# ft 3
53.Well Location:
_) 5fF F�t� 'VV4 4 & 1, � fL my 1-
EL
Facility/Owner Name Facility EDP R 8.
.`M W�l- 9.0. R ft
Physical Address,City,and Zip 2l:1t1311fA1tKS " 7'775T-7777
r OLIL
County Parcelldentification No.(PIN) NOV - 5 2021
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2Z Certifi lion:
5
(ifwell field,one lat/long is sufficient)
35 2 I L N Z o 3 � W •
Signature of Certified Well Co or pate
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the wells)vim(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 KlNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the native ofthe
repair under 421 remarks section or an the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page4o provide additional well site details or well
8.Number of wells constructed: i construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the sane rn»strncdon,.wu can
submitoneform _ SUBMITTAL INSTUCTIONS
9.Total well"depth below land surface: I (D (fL) 24n. For All Wells: Submit this I form within 30 days of completion of well
For multiple wells list all depths ifdi(/erent(example-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: H 0 00 Division of Water Resources,Information Processing Unit,
If water level is above casing.rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: I Iln addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of Hell
12.Well construction method: Rotaryconstruction to the following:
(i.e.augw,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
13a.Yield(gpm) y 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.
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013