GW1-2021-08168_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD
For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information:
k14.)YATER:ZONES
Bryant Smith FROM TO I DESCRIPTION
Well Contractor Name 180 ft 185 ft l
e
2571 ft rt
NC Well Contractor Certification Number 15 OUTER CASING(for multi-cased:cells OR LPTER(if cable
FROM 1 DUME1FJt THiCh1V'FSS AIATERtAL -
Green River Well &Pump it. ft in.
x, Company Name 16ANNER WING'OR]
TUBING thermal cjosed 100 '
cx 20100108206 FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 1 e. 60 ft
6 in 21 PVC
all applicable rrellpermits(i.e.Counh;State,Variance,Injection,etc.) R A, in
3.Well Use(check well use):
.ITt SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSME THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IOResidential Water Supply(single) & ft in.,
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18 GROtff,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-'Water Supply Well:❑ anon 0 FL 15 11- Saltrete Mot&Pour
❑Monitoring ❑Recovery, ft. &
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELFACK(ifa' lkable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAIPIACEAIENTAIU MOD
R. ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
20.DRUAANG,LOG attach sidditional sheets if n )
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(ralar,hardness,saitfrock type,grain ter,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 R 10 & Red Clay t
4.Date Well(s)Completed:
1-6-201t i Well ID# 10 40 R Gravel,sand&water
Sa.Well Location: qB ft 55 ft Brown Shell
Thelma Levi 55 & 205 It. Granite
fL ft (�
Facility/Owner Name Facility IDk(if applicable) t
ft ft
2182 Bobs Creek Rd Zir. 28790 & IL NOV - 5 202�
Physical Address.City,and Zip 21:.RE11TArfKS:
Henderson
Countv Parcel identification No.(PIN) ! .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification
(ifwell field,one lat/long is sufficient) •
35 11 00 N 82 28 02 W 1-8-2$
Signature of enificd Well Contractor i Date
6.Is(are)the welt(s): ®Permanent or ❑Temporary
By signing this form.I hereby certifj•whirl the well(s)uus(were)conrtnrcled in accordance
with 15A NCAC 02C.0100 or I5A ACAC 02C.0200 Well Constnrction Standards and that a
7.Is this a repair to an existing well: ❑Ves or FlNo cagy of this record has been provided to the well on•ner.
If this is a repair,fill mtt known well consinrction information and explain the nature of the
repair tinder=21 remarks section or on the back ofthis form. 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: 1 construction details. You may also attach additional pages if necessary.
For multiple n jection or non-water supply wells ONLY with the same consirrtction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 205 (ft) 24a. For All Wells: Submit this j form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. s (in.) 24b.For Infection Wells ONLY: J 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
12.1Ve11 construction method: Rotary construction to the following_
(i.e.auger,rotary,cable,direct push,etc.) �..
Division of Water Resources,+Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: 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 %veil 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
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