GW1-2021-08053_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal use ONLY:
'Ibis form can be used for single or multiple wells
1.Well Contractor Information:
Chris King 14wATERZONllS 't
FROM TO I DESCRIMON Well contractor Name daft `el<tt
3415 ft ft
NC Well Conductor Certification Number
15 OVTEItCASING §kmul4-cssed;w •ORLINER'Ifa Ikable`=
FROM To DIAMETER THICKNESS MATERIAL _
Green River Well& Pump h. ft in.
Company Name 16.,INNER"CASING OR TUBING"`eothermat closed-loo :
2.Well Construction Permit#
7 O W011J t i o 4'+ FROM TO DIAMETERTFIICKNESS ntATER1AL
tt
List all applicable wyll permits f e.County,State,Variance,I lesion,etc-) ft s is 21 PVC
tZ ft is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM I TO I DIAMETER Y SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n ft. in
❑Geothermal(Heating/Cooling Cooli Supply) OResidential Waters B' ft in.
( EJ n€ uPP Y) apply(single)
❑lndustriallCommercial ❑Residential Water Supply(shared) JILIGROt1T
FROM TO •MATERIAL EMPLACEMENT METHOD&AMOUNT'
OlrriRation R Sa
Non-Water Supply well: 0 ft 20 lrete Mix&Pour
❑Monitoring ❑Recovery It. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SMiD/GRAYER-PACK rfa 'licabte
❑A Ulfer$t0 FROM TO MATERIAL EA7PrACENiEhTIHETHOD''
q rage and Recovery ❑Salinity Barrier It.
Test ❑Stormnater Drainage
❑Experimental Technology ❑Subsidence Control & fc
❑Geothermal(Closed loop) ❑Tracer
<:2q:'DRIII;IIVGLt7C ittactiaddi6oiialsbeetsit"
FROM Im DESCRD`TION(mlar,bwdaes%swiftmk �rainsie etc) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft
Q It _5ANVA (AAA
. wo M
4.Date Well ft ft
s)Completed: I L@�Well ID# O R• D ft �
xsA
5a.Well Location.
+ �V�1� ` y ^Q ft t o ft � .'.�
1� \I����Facility/ONncr Nit{ame Fatality ID/'(ifapplicable) rt. fLR ft.
Physical Address,City,and Zip I+
21 REMARKS
City Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Certification
(ifwell field,one lat(loug is sufficient)
?-(, 7-Q' N w
ature ofCertified Well Con Date
6.Is(are)the well(s): ®Permanent or ❑Temporary Br signing this form,I hereb,certify that the wells was Sn S f J f1' (1 (were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has beenprovided to the well miner.
If thn is a repair,full mrt known well construction information mud explain the nature of the
repair under=21 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
8.Number of wells constructed: + construction details. You may also attach additional pages if necessary.
For in Itiple injection or non-water surppb,[fells ONLY with the same consbnctlon,tmr can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: v (f.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmhiple wells list all depths ifdierent(erample-3@200'and 2@100) construction to the follov-,ring:
10.Static water level below top of casing: Z C (ft.) Division of water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Ce I nter,Raleigh,NC 27699-1617
11.Borehole diameter: 6 OIL) 24b.For Injection 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 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 i14ail Service Center,Raleigh,NC 276994636
I
13a.Yield(gpm)_� _ Method of test: ar 24c.For Water Supply&Injection iWells:
Also submit one copy of this form within 30 days of completion of
13b Disinfection type: FiTli Amount well 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 Aueust 2013