GW1-2021-08120_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King 44.�WATERZONES t {
FROM TO Iy DFSCPJ[rflON
Well Contractor Name ft. fL
3415 & &
NC Well Contractor Certification Number .1&OMER':CASING'for`'l nl6 eased,well4 OR I3NER rf' "'b1e
FROM I TO IDiM1EI'ER THICICNFSS MATERIAL
Green River Well & Pump & fL ;n
Company Name W.ON ER CAS ING'OlUt BING; `euthn-miiidasedauo
FROM TO DIAMETER I TILCKNESS I MATERIAL
2.Well Construction Permit#: Z.!'00 7 1 fL I fL 6 1D 21 PVC
List all applicable well permits(i.e County,State,Variance.L jectioA etc.) ft.
Well Use(check well use): ,'17..SCREEN _
Water Supply Well: FROM TO I DIAAISTER I SLOTSIZE I TMCKNESS I MATTRIAr.
❑Agricultural ❑MunicipaMblic & tL in
❑Geothermal(Heating/Cooling Supply) 91Residential Water Supply(single) it fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENTMETMOD&AMOUNT
`
❑Lei lion Non-Water Supply Well: 0 fL20 fL Salvete Mbi&Pour❑Monitoring ❑Recover) IL ft
Injection Well: 2 fL
❑Aquifer Recharge ❑GroundwaterRemediation 19:SANDJGRAI'EL'YACg r[iii; ble
TO MATERIAL EMPLACEMENT i%trr uoD ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R. �
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control
:IO;DRII.LING:I.00.titlath:adddional'sheets'ifa ) A '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREMONteohr,hudneu suiVroek yia.ere
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) p fr i fL Sw qi
4.Date Well(s)Completed: Well 10# fL o ft Ai D O e l m- �
C, R fL /' t io- E
fL fL C f t
5a.Well Location:
-Alm &KA IL ft.
Facility/Owner Name Facility ID#(if applicable) ft
Physical Address,Cit-v,and Zip ;.21:REMARI{S
RCV'�\A LV AlN I A
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C 6ca ;:w�
(if well field,one lat/long is sufficient)
% 1
4 5 1 N Z 3 f� '-I Td w
3 5 1
ugnature of Certified Well Co tract pate
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby cerr0y'u the well(s)was(were)constntded 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 well• ❑Yes or allo copy of ths record has been provided to the well owner.
/f this is a repair,fill out knower well construction information and explain the nature of the
repair under 421 remarks 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some comhnction,you can
submitoneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 2 J (it) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list aft depths if different(example-3@200'and 2©10ir) construction to the-following:
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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-Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.) �
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY WQELI.S ONLY: 1636 Marl Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) U Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131L Disinfection type: HTH Amount, well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013