GW1-2021-08115_Well Construction - GW1_20211105

'LL CONSTRUCTION RECORD
fix—m can
be tDed for single or multiple wells =z --se
T.R ell Contractor Information:
Chris II nWATMZ 'MM
DESr]tD'F1ON rxox
"`rL'Ccsnractor?vame TO -
3415 ft
& fL i
NC Well CoactorCertificationNumberO11TER' WII`0g.Y.INE1t
FROM TO
►f_a" ."ble
Green River Well& Pump & DWI TEI� MATERIAL"
iz Company Name in.
16.1NNSRC)1SlNG1R=TL1BiN6 Cwt6�rmst
rr//1 FROM TO tldYdf-l00
2.Well Construction Permit 4--S YY 2 G DIAMETER ,n,AT
List all applicable KeA emits rye Co ft it s in. 2�
Pe use,.err ar>I.�e an.etc.) P/C
3.Well Use(check well use): R & is
Hater
PPIS Well: FROM To
..DL4RiETER SLOT SIZE THICKNI SS
❑A�icuitural ❑Municipal/Public B 8• in.
❑Geothermal(Heating/Cooling Supply) VIResidential Water Supply(single) & ft in
❑IndustriaUCommercial ❑Residential Water Supply
❑ PP Y(shared) no
Irrination
MATERIAL s EM IACEMENT a'EIAOD&AMOtn%r>
TO
Non--Water Supply Well: ft 20 rc Salaete' Mb(&Pour
❑Monitoring ❑Recovery R &
Injection Wen: ft
❑Aquifer Recharge ❑GroundwaterRemediation 19:SANDIGRAVELTACK(Ifa lieablo
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMIK ACEM1tEMr nlErnmi
❑Aquifer Test ❑Stormwater-D-inage
❑E.xperimantal Technology []Subsidence Control fL
R
❑Geothermal(Closed Loop) ❑Tracer 2U:11RII:LlNG1: G.a&aeh11H6ihoDafsheefsifIlceessa r
m?ROAf TO❑ DESCRIPTION(robe hardmm,sa,yr�, ram `
Geothermal(Heating/Cooling D—m) ❑Other(explain under#21 Remarks) 0 ft 2 fL ffi etc.)
C e cI
4.Date Well(s)Completed J a greB ID# S �� fL g. L 4 T
52.Well Location: 50 IL SS rr 0 cll h S� C-
S-5 ft ors ft.
Facility/owner Name & ft.Facility Wff(ifapplicable)
e aT �r e t!�`C i✓ L 2J
Physical Address,Cu_v,and j h• &
_RV��tr-�ocd�o� zI. MAR1ss.
County parcel identification No.(PiN)
56.Latitude and Longitude in degrees/minoteslseconds or decimal degrees.
I `
(ifwell field,one lat/long is sufficient) 21 Certificati
Ic
W �f S 2
6.Is(are)the wen(s): ®permanent or ❑Temporary Certified Well Contractor Daze ,
By signing this form,I hereby certify that the weB(s)was(were)canstraded in accordance
7.Is this a repair to an existing well: ❑Yes or ®No With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wen Consh,tction Standards and that a
1f flris is a repair,fill out known well construction information and erplain the nature ofthe roPY of this record has been provided to the well owner.
rePair r-der#21 remarks section or on the back of this fornr. 23.Site diagram or additional well details:
You may use the back of this page to'provide additional well site details or well
F Number of wens constructed:su construction details- You may also attach additional a
For multiple injection or non-water supply W=ells ONLPwith the saint°onshuctlon ymr can pages if necessary.
submit oneform. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: ( ) 24a. For An Wells: Submit this form within 30 days of completion of well
For multple Wells list all depths ifdi erent(example-3 200 •and 3QI0,0) construction to the following.
10.Static water level below top of casing:
If water level is above casing,rise-+^ (ft) Division Of Water Resources,Information Processing Unit,
1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter. s (n) 24b.For Infection Wells ONLY: In addition to sanding 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: RO�ry-auger, construction to the following:
ie rotary,cable,direct push,eta)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
� 1636 Man Service Center,Raleigh,NC 276MI636
13a.Yield(gpm) Is Method of test: Air 24c.For Water Supply&Injection Wells:
HTH Also submit one copy of this form within 30 days of completion of
I3b.Disinfection type: Amount: well construction to the county health Ide partrnant of the county where
constructed.
��rm GW-1 North Carolina Department of Environment and Natural Resources_Division of Water Resources Revised Au
gust