GW1-2021-08106_Well Construction - GW1_20211105

CONSTRUCTION RECORD For batmal Use ONLY:
be used for single or multiple wills
•actor Information:
9 M WATt&zcrosS
FROM TO DESCIRIPRON
Weil Contractor Name l li0 fL Li i j R. 30 1 t FeA 16RAVEL
3415 R. It.
NC WdI Contractor Catificarim.Nsz
]S01r"R'CA51NG for wdti:O1tTQISR_
FROM TO DiAMEMR THICKNESS H11 MATERIAL
Green River Well & Pump & �. .
Company Name <'l6:IN1Vl+dt!CASING.OR7'UBRVG elosed••1 �':. .' _:
� ', FROM TO DIAM&UM THICKNESS IA MATERL
v
2.Well Construction Per ms= I fi. 6 in. PVC
List aAapphwbfe web:perm ,-fs."r:. ri'r Sri Ixjedion,etc)
tt ti m.
3.Will Use(check wen use) a-17�Sf7tEEN ,�1 j1;K .
Water Supply Well- FROM TO DIAMSIER -SLOTSI7.S THICKNESS I MATERUL..;.
OAgricultural OMunicipal/Pnblic B. R. m
OGeotheumlal(Heating/Cooling Supply) BResidential Water Supply(single) S R im
❑Industrial/Commercial OResidential Water Supply(shared) `iltl':CROt1T
FROM TO MAIM" ..RMPIACSMRNr M61HOD&AMOUNr
Olrri _on 0
Non-Water Supply Well: fL20 fLSakrete Ma&Pour
ft. ft.
OMonitoring ORecovery
Injection Well: R &
OA uifer Rech >A SANDIGRAVEI PACK "q urge OGroundwater Remediation
OAquifer Storage and Recovery OSAinity Barrier FROM Im MATERML I HMPLACENEWWWITtOD
R R
OAquifer Test OStormwater Drainage A R
OExperimattal Technology OSubsidence Control
24 DRILLING1= ait4uli addifi6ual°sbeeb R
OGeothermal(Closed LAMP) OTracer FROM TO DI�CRIPITON colt,6udaes,so0rmek sar,ez `:.
OGeothermal(Heating/CoolingRetum OOther fL k
(explain under#21 Remarks) (' l 0
f
4.Date Well ��s)Completed: a l Will IDO O S — ft. 5�
Sa Wen Luca,/li R 8 vEon: fL
�R�j tom. Yy fL � R
Fa�ci/lit m
Qy/OwmerNae Facility WN(ifapp&cable) fL R
1 f\ ►Y _R l Y� R. fL
Physical Address,City,mid Zip r
Couary Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees(minutestseconds or decimal degrees:
22 C catioa:
(if well field,one Iad ffu long is saient)
3S c SK N Ll F) W :.,;; .ivy
�Z �.
Signature ofCatified Well Contract9F Date
6.Is(are)the we l(s): ®Permanent or OTemporary
B3'signing this form,I hereby certify that the well(s)was(were)constructed to accordance
with 15A NCAC 01C.0I00 or 15A NCAC 01C.0200 Weft Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No copy ofthis record has been provided to the welt owner.
If this is a repair fill out known well construction Information and esphdn the nature ofthe
repair under#21 remarks section or on the back of dWsform. 23.Site diagram or additional well details:
t You may use the back of this page to provide additional Well site details or well
!I.Number of wells constructed: I construction details. You may also attach additional pages if necessary.
For muf*k a jectiai or non-water supply wells ONLY with the some construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: "-1 (ft) 24a For All Wells Submit this form within 30 days of completion of well
For mdttpfe wells list aAdepd u if dii ferenr(example-3@200 aaandd2�2©100) construction to the following:
IlL Static water level below top of casing: (JlJ (fL) Division of Water Resources,Information Processing Unit,
If water feud is above casing,use--•• 1617 Mail Service Center,Raleigh,NC 27699L1617
11.Borehole diameter. 6 (in.) 24b.For Inieefion Was 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
(Le sager,rotary,cable.direct posh.etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699LI636
13a Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells
Also submit one copy of this form j within 30 days of completion of
13h.Disinfection type: HTH Amount. well construction to the county health department of the county where
constructed_ 1
i
Font GW-1 North Carolina Department of Firviromnent and Natural Resources-Division of Water Resources Revised August 2013