GW1-2021-08108_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD Far Internal Use ONLY;
This flan eer be used for single or muhiple wells
1.Well Contractor Information:
Chris King I, oni TO I D, turi,oiv
Well Comractor Name
rJ I ft
NC Well Com morCertificationNumb= IS OUTER:CASING tor`.®IhtisedweBs O1tIII�t'd
FROM 1D DiAMET TffiC@1SSS MAT6RTAL
Green River Well& Pump fL fL
Company Name '16`:INNffK'CASINGORTUBING dade"oo
_ Z 1 FROM TO DIAMETER THICKNESS MATERIAL
2.well Construction Permit#: 1 rt 710 fL 6 in. 21 PVC
List all cpplicable—Uperma(Le.Comity,State,Vw mxz byeWon,etc.)
ft R in.
3.Well Use(check well rise):
I7.SCREEN
Water Supply Well: FROM ITO DIAMErER I SLOTSME I TIUCKNFSS I MATERIAL
❑.Agricultural ❑MimicipaVPublic R ft i-
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) R fL in.
❑lndustrial/Commacial ❑Residential Water Supply(shared) :11,GROUT
FROM TO...> /.�. MAT
ERIAL FaNPLACFMaNTME IM&AMOUNT
❑Ira aon 0 r` 20 sakme Mix&Pour
Non-water Supply Well:❑Monitoring ❑Recovery fL R
Injection Well: ft R
❑Aquifer Recharge ❑Groundwater Remadiation 19.SAND/GRAVEL, a
F1NPIdCEa(FXI'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL MIKIMODR �
❑Aquifer Test ❑Storrawater Drainage
❑F_xperime ntal Technology ❑Subsidence Control S ft
20 DRII3dNC'�I.00 attaaradd'itio`nal aLeets=if'.
❑Geothermal(Closed Loop) ❑Tracer FROM To DBSCRIFFRIN avier, =Wank `s mete
❑Geothermal(HcatinglCooling Return ❑other(explain under#21 Remarks) I t) fL r T- ft
4.Date Weu(g)Completed: (6 V5 Z1 Well ID# 1 ft o fL Ci R at
R R
Sa.Well Location '> ©
Moil
FacHity/Owner Name Facility W#(ifaWfice le) RAN rrr_
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ft S
fL
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Physical Addkcss City,and Zip ;aZ1 REMARKS.:::
[OL V-
Cry Parcel Identification No.(PRE NOV
5b.Latitude and Longitude in degmes/minutt./seconds or decimal degrees:
(ifwell field,one hNimig is sufficient) 22.Certification: j
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3 .z
5 11 7-5- N ® 2 Z�7 1 .'� w
Sigmene of Certified Well Date
6-1s(s-)thewel1(s)a ®Permanent or ❑Temporary By d-forth,I hereby ratify dew the wells)wat Om)constructed m accordmtce
with ESA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnteaon Statdw&and that a
7.Is this a repair to an existing welt ❑Yes or RlNo copy of this record has been provided to the well owner.
9dw is a repair,fill out inown well constrndion mprnmtion and eiplarn the mature of the
repro under#11 rear section or on the 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
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mubVle nyec*on or non-water:apply wells ONLY with the were eondmalon,ym can
submit meform. SUBMITTAL INSTUCfIONS
9.Total well depth below land nwfaex: 7-1L ZI (fL) 24a. For AD Wells Submit this form within 30 days of completion of well
For muhiple weAs list all depths if&ffmW(ermnple-3@200- m-f2(a)1003 construction to the following:
10.Static water level below top of casing: (P C (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2709LI617
11.Borehole diameter. 6 (in.) 24b.For Injection 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 Lion of well
12 WeD construction methetd: Rory construction to the following:
(Le roger,rotary,cable,ditectpwk etc)
Division of Water Resourees,Vndetgroand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method ft., Air 24c.For Water Supply&Injection well.:
Also submit one copy of this form within 30 days of completion of
131L Disinfeetion type: HTH Amount: vwx construction to the county ht department of the county where
constructed.
Fenn GW-1 North C:ootins Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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