WI0100319_WELL CONSTRUCTION RECORD_20141110

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Anthony Bryant Smith
Well Contractor Name
2571" "
NC Well Contractor Certification Number#s
Green River Well & Pump1`.
Company Name q V !� I 6 ^, (1/�
2. Well Construction Permit #: WT t � / I
List all applicable well permits (i.e. County, State, Variance. Injection, etc.)
3. Well Use (check well use):
❑Agr�icultural
Ofseothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Well:
❑Aquifer Recharge
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
OeEbthermal (Closed Loop) ❑Tracer
❑Geothermal
DOther (explain under #21
4. Date Well(s) Completed: G V/ WeU 1D#
5a. Well Location:
&maid
Facility/Owner Nam Facility ID# (if applicable)
/ 9Z 13)vc 0,/l tigk,L I-og -z9hc
Physical Address, City, and Zip
Ri)1~l„t�l
County Parcel Identification No. (PIN)
For Internal Use ONLY:
14. WATER ZONES
FROM TO DESCRIPTION
ft ft.
ft. ft.
15.OUTER CASDYG for mull -wed wells OR LINER if file
FROM TO DIAMETER THICICNFSS MATERIAL
ft. ft. I in,
16. INNER CASING OR TUBING eothermal dosed -loop)
FROM TO 1 DIAMETER THICKNESS MATERIAL
,I ft )z) ft ! M� * /i o
O ft' A% ft 1 hL i O
17.SCREEN
FROM TO DIAMETER SLOT SITE THICIQVESS MATERIAL
It. ft in.
ft ft in.
la. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD di AMOUNT
Q ft. ! oft
ft ft.
19. SAND/GRAVEL PACK if a ble
FROM I TO MATERIAL I EMPLACEMENT METHOD
It. ft
ft ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color, hardness, "fl/rock tipe, grain srze, etc.)
® ft k
ft. L 'n SU"
1' ft 4 ft -7 0 ft.
9 C!
ft
ft ft
ft ft.
ft. ft.
21. RFMARKS
5b. Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22. Certification:
(ifwell field, one lat/long is sufficient)
�'� I✓ •L5 �fttJ N C%5'/Z`' /f% OY W D
ignahtre of ertified Well Con etor Date
6. Is (are) the well(s): ❑Permanent or @Temporary
7. Is this a repair to an existing weft: ❑Yes or
If this is a repair, fill out known well construction information and explain the nature oj'the
repair under r.2/ remarks section or on the back oo{f this form.
& Number of wells constructed: J
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form. r
7
9. Total well depth below land surface:G}�"; �e✓ / - 2') rJ (fL)
For multiple wells list all depths if & ferent (example- 3@200' and 2@lW )
10. Static water level below top of casing:
If water level is above casing, use "- "
11. Borehole diameter: 6 (in.)
12. Well construction method: Rotary
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test: Air
13b. Disinfection type: HTH Amount:
(f.)
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or 1 SA NCAC 01C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection 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
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection wells: RECEIVEDIDENRIDWR
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed. N 0 V 10 2014
Form GW-1 North Carolina Department of Environment and Natural Resources— Division of Water Resources Water Qu ftD0rlai
Operations Section