GW1-2021-08055_Well Construction - GW1_20211105

WELL CONSTRUCTION RECOPY" For Internal Use ONLY:
This form can be used-,r gi_.<;multiple wells
1.Well Contractor Information:
Chris King 14.%VATERZONEs
t'RObiT7O 7 ,DESCRIPTION
3415 ft. R
NC R':i Cc-?=s Certification Number I&OUTER:CASING"for mnitrrased weIIs'"(lR";I:IlNER ifa hcalile'
FRObf TO DIAMETER
THICKNESS MATERIAL
Green River Well & Pump & i.
Cc--sn'Name 16:INNERCASING:OIt..- ING( ?ddsed-too
{{ i /� FROM TO DIAMITER THICKNESS MATERIAL
2.Well Construction Permit#: Q 1 0 { 5 Z G ft. fL 6 in. 21 PVC
L;c aH applicable urll permits fr.e.County,State,Variance,Injection,etc.)
ft ft. In-
a.Well Use(check well use): 17..SCREEN
Rater Supph'Well: FROM TO DN11fETER SLOT SIZE THICKNESS I t1LATERLIL
!bicultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) & ft
❑industrial/Commercial ❑Residential Water Supply(shared) ;iB:CROUT .- ":...,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
"
❑Irrigation 0 ft 20 ft. Salvete Mix&Pour
Von-Water Supply Well: (t &
❑Monitoring ❑Recovery
Injection Weil: & &
❑Aquifer Recharge ❑GmundwaterRemediation 39.5AND/GRAVEUPACK•',fa 'lic e
FROM TO MATERIAL EMPLACEIIIENTMErHOD'
❑Aquifer Storage and Recovery ❑Salinity Barrier ft �
❑Aquifer Test ❑StormwaterDrainage ft
❑E.eperimental Technology ❑Subsidence Control
:-20:DRILLING LOG'attaeb additional sheets if n
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soill ek type,grain sim,etc.) `
❑Geothemral(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q fc r R R t<
Z , / ft-
ft
4.Date Well(s)Completed: 1 ZZ( Z Well D# N
0 rt ® rt 1�is (�
5a.!Veil Location: '�,t�
n ft '� I lei
1✓f N POL-, G O� ft ft.
FacilityiOwner Name Facility ID#(ifapplicable) )
ft fL il l
L- 1 Li) t l F1D el'� -L-Tv� fL ft NOV
?021
Ph%siiccalAddress.City,and Zip fQ 21:REMARKS,
Count% Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cerlif 'lion-
(ifwell field,one tat/long its sufficient) �j /, i 2
2
OW—ure of Certified Well Co Date
6.Is(are)the w•ell(s): faPermanent or ❑Temporary
Bi signing this form,I hereby certify that the well(s)was(urre)constructed in accordance
With 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Ycs or allo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under=2l remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back:of this page to provide additional well site details or well
S.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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
'j �
9.Total well depth below land surface: `9 (ft.) 24a. For All Wells: Submit this form writhin 30 days of completion of well
For multiple wells list all depths if dierent(example-3@2200'and 2Q100') construction to the following:
10.Static water level belowtop of casing: (110 (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 (in.) 24b.For Infection Weils ONLY:f In addition to sending the form to the address in
24a above, also subunit a copy of jthis 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 Mail Service Center,Raleigh,NC 27699-1636
2
13a.Yield(gpm) -/ Method of test Air 24c.For Water Supph&Injection WeUs:
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 Resoorces Revised August 2013