GW1-2021-08041_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information:
Chris IGng
FROM TO DESCRIMON
Well Contractor Name ft It.
r
3415 ft R.
NC Well Contractor Certification Number 1S Ol1TEIt(A- MG.formula-rived`MIS)Okl:. j lElt rfa
FROM TO DIAML-TFR 71MCRNESS MATERIAL
Garen River Well&Pump ft ft
Company Name itri INNER CASING OR TGBIAfG dated!oo'
{ FROM TO DIAMETER IA 7MCKNESS MATERL
2,Well Construction Permit#: 2i0 1(1 o I Z-1 es►7 1 It. L '-t & 6 in. 21 PVC `l
List all applicable well permits#it Comet};Stale,Variance,Ljeetion,etc) ft ft oL
3.Well Use(check well use): 17Sf.1t1iEN` :..c:
Water Supply Well: FROM TO I DIAMETER 11 SLOT SIZE I THICKNESS `..'111ATFRrwr"
❑Agricultural ❑MunicipaUPublic R. ft
❑Geothermal(Heating/Cooling Coolin Supply) FIResidential Water Supply ft R rn
( $/ g WP Y) uPP Y
❑lndustriaUCommercial ❑Residential Water Supply(shared) '18lG1tOUT
FROM TO I MATERIAL EMPLACEMENT NIMOD&AMOUNT
❑rrri lion 0 & 20 f1 Salvete Mbt$Pour
Non-Water Supply Well:
it. ft
❑Monitoring ❑Recovery
Injection Well: & &
❑Aquifer Recharge ❑Groundwater Remediation ;19 SAND/GRAVEL PAC11,da li able
EMP
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To DATERIAL LACEMENT MUMOD
ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20 DRILLLIlVC LOG attiiih addt6orialslieets if
❑Geothermal(Closed Loop) ❑Tracer FROM To D (color,hardness,smllrocktyM grain fire,era
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) ft fL "
4.Date Well(s)Completed: / Lii M Well ID# ft 1 & �vG
ft 90 fL
Sa.Well Location: A; ft ft _ , (
TIE-
!V
ft ft
Facility/Owner Name Facility IDM(if applicable) ft ft
�'� l�►RRy 41)� � r11?CJ(�iIAL �• ft
Physical Address,City,and Zip 21i REMAttt{S.
4,5NOV
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minuteslsecouds or decimal degrees: 22•Certification
(ifwell field,one laVlong is sufficient) '• /1
3� i"1 31 N S Z 33 43 W
Sibnrature of Certified Well Conirn Date
6.Is(are)the well(S): OPermiment or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Stanrdardr and that a
7.Is this a repair to an existing well, ❑Yes or EINo copy ofthis record has been provided to the well owner.
Ythis is a repair,fill out known well conrtrmction information and explain the nature of the
repair render all remarks section or on the back of this form. 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 h jeetion or non-water sWA,wells ONLY with the same construction,you can
submit one form. LL SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: -1 (fL) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(centuple-3@200 and
j2t�t�t 1100') construction to the following:
10.Static water level below top of casing: IL (� (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: 6 010 24b.For Injection Wells ONLY: iln 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 push,etc.) 4
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LO Method of test: Ai 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 health department of the county where
constructed-
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I