GW1-2021-08048_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For internal Use 0 Y_
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King 1 L�YATER ZONES }
FRO161 TO I DESCRWrtON
Well ConnacwNam & ft
3415 IL ft
A'C Well Contractor Certification Number ,'15.OUTER:CASING for=molfi cnsed*dh.ORLINER'if i` ` ble
FROM TO DIAMETER I TH►CIQIESS MATERIAL
Green River Well&Pump ft & in.
Company Name 16.-INNEK,CASINGOR.TUBLNG(Reatheh3igeinke64BOTiI
` Z� 0 FROM TO utAmETER THICKNESS MATERIAL
2.Well Construction Permit#: W i DO i � -7 (Q � ft. � R, s in. 21 PVC
List all applicable well permits(i.e.Cowry,Syate,Variance.Irjeetion,etc.)
ft. rL in..
3.Well Use(check well use): 1T'SCRESA
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICKNESS I MIATERIAL '
❑Agricultural ❑MunicipaUPublic R. ft in.
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft• ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) >l>I:GROUT q;
FROM TO MATERIAL EM'PLACEME`T METHOD&AMOUNT❑Teri anon O 2 rut ��� Ma&Pour
Non Water Supply Well: 20
❑Monitoring ❑Recovery, ft &
Injection Well: R. ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAVEL PACK da cable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRODt ft TO
TO MATERIAL EMPLACEMENT 11IETHOD
❑Aquifer Test ❑Stmmwater Drainage
R ft
❑Experimental Technology ❑Subsidence Control
20:DRHJ"G Li3G(tit tacL additional sheets if n
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(mler,hardness.suill—k type, sae,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q .R ft
S l v
4.Date Well(s)Completed:lid ZU ld
Well!D# ft ft (-
5a.Well Location:
_ ft
yTE
t
.�Wit; (�1it'3kiii ( tr'I 1 QRRrS & ft i1t
Facifity/Owner Name Facility 1139(if applicable)
ft ft
105 Damce ft
Physical Address.City,and Zipm
21.RB11iARIGS
NUV5 2021
County Parcel Identification No.(PTI)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i
(ifwell field one lat/long is sufficient) 22 Cer¢(i on: VC:
35 l ��ri N 2 3 1 i � W f l�..r �_(9 -2
SijKiire of Certified Well Contras Date
6.Is(are)the well(s): GdPermanent or ❑Temporary
By signing this form,1 hereby certify that the Well(s)vnat(were)constnicied in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C A200 Well Construction standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy ofthis record has been provided to the well ou ner.
jthis is a repair,fill out known well construction information and explain the nature of the
repair tinder 21 remarks section or on the back afthis form. 23.Site diao—ram 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 same constmetlon,you can
submit one form. ++ p� SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 1 1 (ft) 24a. For All Wells Submit this form within 30 days of completion of well
For mrdtiple Wells list all depths tf dif ferent(example-3Q200'and 2@1000 construction to the fol lowing: I
10.Static water level below top of casing: GHQ 00 Division of Water Resources,Information Processing Unit,
If ureter level is obare 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 constriction 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 D4ail Sendce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t C. 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- well construction to the county health department of the county where
constructed. I
Farts OW-1 North Carolina Department of Emin mm ent and Natural Resources-Division of Water Resources Revised August 2013