GW1-2021-08052_Well Construction - GW1_20211105

.WELL CONSTRUCTION RECORD
For Internal Use ONLY:
x his form can be used for simile or multiple wells
1.Well Contractor Information:
Chris King 14,LWATER-ZONES
FROM TO DESCRIPTION
Well Contractor Name fL &
3415 IL ft
NC Well Comiactor Certification Number SS
FROM DIAMETM TIHCkNESS MATERIAL
Green River Well&Pump fL & in.
Company Name -ASINGOR-TUBING(a6ii 'diised4oaiY��.
I&INNE&C
FROM TO 0 THICKNESS MATERIAL
2.Well Construction Permit#- 0100 1 Dq -I- 1& 6
List all applicable well permits ri.e.Cmmq,.S?;a1e Variance Injection etc) 21 PVC
3.Well Use(check well use): 17 ft. in,
Water Supply Well: FROM I To I DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ElAgricultural OMunicipalftblic ft• ft. in.
0(ictithennal(Heating/Cooling Supply) OResidential Water Supply(single) ft. &
DlndustriaYCommercial 0 Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation 0 20 M Sakiete Mix&Pour
NonAl'ater Supply Wen:
OMonitoring DRecovery,
Injection Well: ft &
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVE VPACK'(ifiioidra61e
D-Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPtACEMENTMETHOD
DAqutfer Test OStormwater-Drainage ft fL
OExperimentall Technology OSubsidence Control
20.DRILLING-LOOL(ittich-idditionA ivnit6ia6y
OGeothermal(Closed Loop) OTrucer FROM TO DESCRIPTION(mlar,hardam witfoek tM grign six,etc-)
OGeothermal(Heating/Cooling Return) 00ther(explain under 921 Remarks) t ft- ft- rsAq
fL W 4.Date ell(s)Completed Well JD# fL
it. ft. W]Lfr-
Sa.Well Location: 5 S-L
fL ft
(>Vio fit. fL
Facility/OwnerName Facility ID9(ifaliplicable) & fL
(Q60 PA-olr—T, 61 %
Physical Address,City,and Zip
':21,REMARKS.----
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22-2t 1
(dwell field,one tat/long is sufficient))
357 13 Q!J N 07, 2- 1 J(0 W
Signature;f'Certifted Well Con
Date
6.Is(are)the well(s): OPermisnent or OTemporary
By signing thisfomi,I hereby certij5,that the well(s)was(were)conswided in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weft Construction Standards and that a
7.Is this a repair to an existing welk- OVes, or ElNo copy ofthis record has been provided to the well owner.
If this is a repair,fill ont known well construction information and explain the nahire of the
repair under 421 remarks section or an 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 injection or non-water szipp4,wells ONLY with the saw construction,You can
submit one form. SUBMITTAL INSTUCHONS
9.Total well depth below land surface: (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ffwater Invi is above casing,use"-" 1617 Mail Service Cinter,Raleigh,NC 27699-1617
11.Borehole diameter- 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
12.Well construction method: Rotary 24a above, also submit a copy of this form within 30 days of completion of moil
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
13s.Yield(gprn) Method of test Air 24c.For Water Supply&InjeCtiffll[Weft
Also submit one coFr.v 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.
Fomi OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resonates Ftexised August 2013