GW1-2021-08107_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be rued for single or ranluple wells
1.Well Contractor Information:
Chris King 14.wAz<satzortss :.
FROM 'M DESCRUT N
Well Contractor Nam R R
3415 R R
`#ISeOIOTF. mbth eased: ORIG�ER;if`
NC Well Contractor CertiticationNumber FROM IGCTOASIPCG fbr I MAT RML
Green River Well&Pump R R
CompanyName 3G�%1NIVSiC`G1Y51NG08=TUglWG _
FROM TO M MA MAETM TMCMMS TERIAL
2.Well Construction earners#: is f'1 Z( g b o R R g m 21 PVC
List all applicable well per—r e.CaaAy,State,Yarianrce,byedran etc)
R R m.
3.Well Use(cheek well use): IX SGRBEN,'
Water Supply Wdn: FROM To MAMSIBR Sims= TRIC"EM ., MATERI"
❑Agricultural ❑MunicipaUPublic R R UL
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) R R in.
❑IndctstriaVCommercral ❑Residential Water Supply(shared) FROM TO MA11MML EMPL&(W*ENI'MSIHOD&AM01JM':
❑Irrt on 0 R 20 R Salmete Mix$Pour
Non-Water Supply Wen:
R R
❑Monitoring ❑Recovery
Injection Welk R R
❑Aquif-Recharge ❑GroundwaterRemediation 19 SANL/CRt1VBI„PACH bk)...
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R R TO XMIM AL EMPLACERUMMUMOD
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
❑Geothermal Closed 20.LRlil:IIYGf:(1G`atlachadditioulaLeetsf
( Loop) ❑Tracer FROM TO DESCAD'1'fON caber,bardaes,soUl—k .,
❑Geothermal Heating(Cooling Return) ❑Other(explain under#21 Remarks) R R '
r® R O R
4.Date Well(s)Completed: Z Well M
R ,
Ss. Location: R R
I1 R R F
FaciWowner Name Facility I11#(if applicable)
Physical Address,City,and Zip '21 itBMARlC5.`f,
?2L iL
County Parcel ldentifirationNo.(PiN) r;•., .. 1'.
5b.latitude and Longitude in degrees/adnutWseconds or decimal degrees:
(ifwell field,one tat/long is sufficient) C ti
3S i 3 Z 7 N Z Zo 5 7 W 10 o
SVQ=of Certified Well Date
6.is(are)the well(* 01 ermanent or ❑Temporary By signing this form,I hereby art{fy weU(s)win(were)oanrtrnctLd in accordance
with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 iPel1 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo ropy of this record has been provided io the well owner
Ifthis is a repair,fell ouuknown well conshudion itfarnralton and explain the mare ofhW
repair roller#21 remarts section or on the back of this fam 23.Site diagram or additional wen details:
You may use the back of this page to provide additional well site details or well
&Number of wens constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water apply wells ONLYwith the same consesefim you can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land sarfaea (R) 24a. For All Weis: Submit this form within 30 days of completion of well
For multiple wells fig all moths f&ferear(eamdple-3@200 and 2@100') construction to the following:
10.Static water level below top of casing: (IL) Division of Water Resources,Information Processing Unit,
If water keel is above oasis$we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (In) 24b.For Injection 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 wastraetion method: Rory construction to the following
(i.e.sager resmy,cable,direct push etc.) i
Dj arm of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cep,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test Ai 24c.For Water Supply&Injection Wells: -
Also submit one copy of this form within 30 days of completion of
131L Disinfection type: HTH Amount well Construction to the county health department of the county where
constructed-
Form GW-1 North Carolina Deperhnerd of Envimament and Natural Resources-Division of itwri sources Revised August 2013