GW1-2021-08119_Well Construction - GW1_20211105

LL CONSTRUCTION RECORD
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Contractor Information:Chris King ntf�ATERZONtjgS,
Well Contactor Nam FROM TO
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NC Wen ConnactorCem6cman Numba
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Green River Well&Pump
Company Nam & in.
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Z Well Construction Permit N: S W 2 n 7 Q FROM TO DJAM
List all applicable wenpenngs re Cowl( ETFR TH'CKNM
Y.&are,Yana IL
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'L 6 In.
27 PVC
3.Well Use(check well am): ft. fL
Water Supply Welk _�JIX
OAgricultural FROM TO SLOTSUZ rin ESS MATERIAL-.
0M,micipal/public ft ft iL I
OG-flm-al(Heating/Cooling Supply) OResidential Water Supply(single) & fIL in.
DlndusftWCommercia[ OResidential Water Supply(shared) 18--GROUT
Ofiri -on FROM TO MATERIAL EMFIe►CEMEN7 0 SVp1y Well 0 & D&ANOtirfr
20 ft- Sakmte Mb(&Pour
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Injection Wdh
0Aquifer Recharge IlGroundwater Remediation f ILL ft
OAquifier Storage and Recovery VIM.VAL Akit
OSalirtily Barrier FROM TOMATERIAL OAquifer Test OStorrnwatcr Drainage JFL ft LA METHOD
C]ExperimcnW Technology OSubsidence Control ft ft
OGeothermal(Closed Loop) DTracer ..20L'DRffAMGL,0G,:::,
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4.Date We"(s)Completed:,_ 93-2-f Well uw & A. I VJ MCI—
Sa.Well Location:
FaCIRWOvincrName
IL ft
Facility lD#(ifapplicable)
ft ft
physical Address,City,and Zip % ft
21.-REMARKS F_�
Parcel I cntifi allo.(PIN) 5 2021
5L Latitude and Longitude in degreesttwnutes/seconds or decimal degrec=
(ifwell field,am haqung is suffcient) 22.Certi
35- 7-14 P
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6-ls(8-)the weH(sy ®Permanent or E3Tclnpor3ryt of Cotified Well ct r Date
By signft this form,I hereby certify that the weg(s)was(were)Can1&udLd in acc,,&,,ca
7-13 this a repair to as existin welk Oyes or 9lNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wen consnueffia,&wdar&and that a
'Vdw's a rePor fin our known well Construdian mfornwhon wd oWlin he nanim of the ccFV OfMu record has been providedto the well owner.
repair under#21 remarks section or an Me back of di&form 23.Site diagram or additional well details:
&Number of wells constructed: i You may use the back of this page to provide additional well site details
For-uWe hV-fian-""-fifer JW1Y weds ONLYwdh the sane canhcd0,% construction details. You may also attach additional pages if necessary. or well
submitoneform -au can SUBMITTAL INSTUCTIONS
9.TOW well depth below land surface. 11 5 -
For multiple wells/waft dqWa lf�vvnr(="Wle 3@_700'aizd2@J00)_(fL) 24AL for_AQWd1&- Submit this form within 30 days of completion of well
10.Static water level below top f casing. construction to the following:
Ywater revel is above caring use (ft.) Division of Water Resources,Information Processing Unit,
11-Borehole diameter.- 6 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Injection ONLY; in addition to sending the form to the address in
12.Well construction method: Rotary 24a above, also submit a copy of this:
h 1 form within 30 days of completion of well
(Le 80M.nab",cable,d—posh,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY DivWon of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,Ne 27699-1636
13a.Yield(gpm) S Method of test Air 24c.For Water SauDly&Inirrii..Wells:
13b6Disinfection type: HTH Also submit One copy Of this form within 30 days of completion of
Amount.- well construction to the county health'department of the county where
constructed-
Norm GW_I
North Carolina DeParunent of Envinnunent and Natmal Resowces-Division Of Water mesour I ces Revised August 2013