GW1-2021-08104_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King Id.WATj RZONEs-
Mfp
o DFSCRIrnoN
well Contractor Name " e.
3415
NC Well Contractor Certification Number IS�'DUTER CASING for fulfi-eased wr&UR:I IlVER f
FROM TO DIAMETER THIC-rNs AIATERML
Green River Well&Pump & ft
Company Name ,10iINNERCASINGOR. BING"eothermil'claie"oo`
t� FROM TO I DIAMETER I THICKNESS MATERIAL.
2.Well Construction Permit#: t. Z ft. ft- 6 is 21 PVC
List all applicable well permits(ice.Counryt Slate,Variance./r0ecrion etc) & 8 m
3.Well Use(check well use): I7 SCREEN,. ;;
Water Supply Well: FROM TO DMAIETER~ SLOTSIZE I THICKNESS I MATERIA4
❑Agricultural ❑Mtnicipal/Public It. & in.
❑Geothermal(Heating/Cooling Supply) KlResidential Water Supply(single) R &
❑Industrial/Commercial ❑Resideauiial Water Supply(shared) 18 CROtTT
FROM TO JMATE TH
RML EMPIACEMENTMEODdoAMOUNT
Non-Water Supply Well:
❑ n- tier 0 fL 20 Sala+ete Mot&Pour
❑Monitoring ❑Recove ft FL
ry
Injection Well: & fL
❑Aquifer Recharge ❑Groundwater Remediation 39SSAND/GRAVEI PACK rf. ble
❑A uiferStO FROM TO nL4TERIAL EnIPLACEMErTrML-MOD
q rage and Recovery ❑Salinity Barrier R. FL
❑Aquifer Test ❑Stormwater Drainage 8. R
❑Experimental Technology ❑Subsidence Control
-20 DRHIMG LOG"sittach additionsl'sheets if .`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(mlor,buaaes%sa'ilhock size,etc.)}
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (� K & i
4.Date Well(s)Completed: Well 1D#
U ft 9 0 ft W CG —
Sa.Well jLocation:
Facility/ONva Name Facility IDS(if applicable)
(�� I.41✓c ��t T?� fL ft. `
Physical Address,City,and Zip k ~
'Po'
Counh• Parcel identification No.(PiN) NOV
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification ...: .
(ifwell field,one Wong is sufficient) I y`
Signature of Certified Well 914''Mr Date
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 I.iA 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 FlNo copy of this retard has been provided to the well owner.
if this is a repair,fill out known well construction information mid explain the nature of the
repair wider=21 remarks section or on lire 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
8.Number of wells constructed: i construction details. You may also attach additional pages if necessary.
For mmhiple injection or non-water supply wells ONLY with the same construction,irou can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 00 24a. For Au Wells: Submit this iform within 30 days of completion of well
For multiple wells list all depths if different(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,
Ifuater level is abm a casing,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the fern 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(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY'V'1'ELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test. Air 24c.For Water Suppy,&Injections Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: well construction to the county h th department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013