GW1-2021-08109_Well Construction - GW1_20211105

NVELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
Chris King 14i':WATEItZONES _
11tOM TO DESCRIPTION
Well Contractor Name ft
3415 fL ft
NC Well Contractor Certification Number 15L`OUTER'GASITiG: moiA sastd;wel�s UR.IC,YNEIL'` f 61e
FROM TO laMMETER THICKNESS MATERIAL
Green River Well&Pump &
Company Name 16;1NNERCASItHG `Olt TUBING "euthelrmat clascd=tod
FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit!#: 5 W'7-k- DO IS i fL 0 fL 6 in 21 PVC
List all applicable well permits(i.e.Count};State,lrarionce,Injection•etc.)
ft fL in..
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT St M r THICKNESSMATERIAL
OAgricultural OMtmicipaUPublic ft. fL in.
❑Geothermal(HeatinglCooling Supply) 91Residential Water Supply(single) fL ft hL
171ndustiial/Commercial ❑Residential Water Supply(shared) 'GROUT
FROM I TO MATERIAL EMPLACEMENT MERIOD&AMOUNT
20 ft Sakre Mot$Pour
Non-Water Supply Well:
fL 8.
❑Monitoring ❑Recovery
Injection Well: fL &
OAquifer Recharge OGroundwater Remediation -19 SANAIGRAVBL PACK da UcatMe .
TO
OAgtrifer Storage and Recovery ❑Salinity Barrier
FROM
ft TO
MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormuaterDrainage R ft
OExperimental Technology OSubsidence Control
Z0 DRIIIA..ING 1i�G:atteehaddi6on87shectsif'
❑Geothermal(Closed Loop) ❑Tracer FROM TO D}SC9tWTION(color,hardems"roek sia,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f fL
fL ft
4.Date Well(s)Completed: Well WN ft. R
C
5a.Well Location:
r .
Facility/Owner Name FactilityID#(ifapphcable) ft ft
W k LLO\N) CR ft ft
Physical Address,City,and Zip .21,REMAJW
Ri3�11
County Parcel Identification No.(PIN) ) _
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22-Certifi lion: N n V 5 2021
(ifwell field,one lattlong is sufficient)
3 5- 2 5 3 Z N 2- o� 5 W
ofCertified.WellCo or.' r,; `'I: Daze
6.Is(are)the well(s): ®Permanent or OTemporary
1N signing this form,I hereby certify the the well(s)ans(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 we1L- ❑Yes or ElNo rnpy of this record has been provided to the well owner.
Ijthis is a repair,fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back of this form. 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: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construedian,you can
submit one form. SUBMITPAL 1NSTUCTIONS
9.Total well depth below land surface: �0 5 (fL) 24a. For All WeRs: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdijjerent(example-3@2W and 2@100) construction to the following:
10.Static water level below top of casing: TOO (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,ruse"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Iniection 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 of well
12.Wen construction method: Rotary construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.) Y
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) 2 Method of test: Air 24c-For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136 Disinfection type HTH Amount: well construction to the county health department of the county where
constructed. i
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of water'Resources Itmised August 2013
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