GW1-2021-08117_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King4 NtA7FICZOI�FBS -., F M
FROM I TO �DESCRIPI'ION
Well Comractor Name ft. ft.
3415 f f
NC Well Contractor Certification Number -O GASINrs for-""multi METERelis}p THICKNESS!!"
i ' 6 TYE
FROItt TO DIAMETER THiCIINFSS MATERIAL
Green River Well$Pump ft. FL in.
Company Name M-INNER ASIPIGUR;IUBIN6 eoiher�il lined! .r
( FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: A l 1�O �q� � 2� � 6 'O' 21 PVC
List all applicable wellpermits(i.e.CmmtK State,Variance,hyedion,etc.)
2 fL is
3.Well Use(check welt use): 37;'SCRSEN <'
Water Supply Well: FROM TO I DIAMETER, SLOT SIZE THICKNESS MATERIAL
OAgricultrtral OMunicipal/Public & ft. in.
❑Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single) ft & rn
❑Industrial/Commexcial ❑Residential Water Supply(shared) 1tI:GRotfr
FROM TO MATERIAL EMPIACEMENTML-MOD&AMOUNT
OIrr `•
Non
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N000n 0 f 20 R Salvete Mix$Pour
Water Supply Well:
❑Monitoring ❑Recov & ft.
Injection Well: ft IL
❑Aquifer Recharge ❑GroundwaterRemediation ,19SAND/GRAtI;'PAt1.K(d `lic>rtSle
'.
OAquifcr FROM TO MATERIAL EMPLACEMENT MEIAOD Storage and Recovery ❑Salinity Barrier It. R
OAgmfer Test OStormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
ZODRHd,IPJG%IiOC attach"addrhoinl'sheetsir'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(cobr,hardaess6 soWrftk size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I R IL
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4.Date Well(s)Completed: Za 21N,�ID#
5a.Well Location: fL IL
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�i�aW C G '
Facility/OwmrName Facility M9(ifapplicable) & f
mskG-Ho&`A 9P
ft
Physical Address,City,and Zip iftt.1 / I /
:21:REMARKS t
n
County Parcel Identification No.(PRE r_
5b.Latitude and Longitude in degrees/minotes/seconds or decimal degrees: 22 Ce 'fication:
(ifwefl field,one IaNlong is sufficient)
tee of Certified Well Con or Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing welt: O Yes or ElNo copy of this record has been provided to the well owner.
If this is a repair.fill out known well construction information and explain the nature of the
repair under=21 remarks section or on the back of thisfomL 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 multiple injection or non-water supply wells ONLPwith the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (Do (fL) 24a. For All Well Submit this form within 30 days of completion of well
For multiple wells list all depths rrf&fferent(example-3@200 and 2@100) corn&uttion to the following:
10.Static water level below top of casing: IL AJ (fL) Division of Water Resources,Information Processing Unit,
Ifuwter letel is abowe casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in_) 24b.For Injection Wells ONLY:I 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.auger,rotary,cable,di-push,etc-)
Division of Water Resources,L Undergroand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tee Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount well construction to the county h�lth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water RI ewurcu Revised August 2013