GW1-2021-08058_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Imemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris King
�4t;`N*lATER'zoNEs
FROM TO. _..'DFSCRIMON• .
R 1 1 R P
Well Contractor Name t r
3415 R R
NC Welt Contractor Certification Number .IS'Ol3TER'CAS1N6 for:molAnsag"ivelb DR2dNER 1fa bl4
FROM i TO DIAInEH'F1t THICKNESS MATERULL .
Green River Well&Pump R it in.
-46� VN 9 WCASINGUR;7'UBING: tuts F:tiaaed ltio
Company Name
Well Construction Permit#: R �
�`� t c Li t Q FROM- TO DIAMETER THICKNESS MATERIAL
2- R is 21 PVC
List all applicable well permits r e.County,State,Yarionce,Injection,etc)
R R in
3.Well Use(check well use): 17:St itEEN, u.t
Water Supply Wen: FROM TO DIAME-rER SLOTSIT& THICKNESS I•MATERIAL_J.
❑Agriculttnal ❑Mtmicipal/Public R R rn
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) & R m
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ini lion
Non-Water Supply Well: R R ��� Mbt$Pour
R R
❑Monitoring ❑Recovery
Injection Well: R &
❑Aquifer Recharge ❑Groundwater Remediation 191SA1VDlCRe1VE_L ACE'tier 'liitiible_. j: z_..,,<:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM R R TO MATERIAL EMPLACEarEM1T METHOD
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
20:DIEIIiL'INGISQG; ittactisAditioilslsheetsd
[]Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(om,hwdaess,s Wok d22.err.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d R a R d 'el
R — �R
4.Date Well(s)Completed: Well ID# R ��R ,) i - —
Sa.Well Location: ft R
Facility/Owner Name Fuitity Mo(ifapplicable) Fly
ft. ft.
Physical Address,City,and Zip
County Parcel ldentification No.(PIN) ,ry L ''.1Ei k i t`)r
5b.Latitude and Longitude in degrees/minatestseconds or decimal degrees: 22.Cer66 lion-
(ifwell field,one lat/long is sufficient)
S 7 q 3 f N Z j�j` W --?1
rgnatmeofCenifiedWell eo Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
!3y signing This form,I he certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing welk ❑Yes or 91No copy ofthis record has been provided to the well owner.
Ijtbis is a repair,Jill out known well construction information and explain the nature of the
under remarks section or on the back ofthisform. 23.Site diagram or additional well details:
(( You may use the back of this page to provide additional Hell site details or well
&Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same coas&ucdon,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdjjerent("ample-3©200 and 2@100') construction to the following:
IQ Static water level below top of casing-. ((t) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11,Borehole diataeter. s 0-) 24h.For Iaiection Wells ONLY:!In addition to sending the form to the address in
24aabove, also submit a copy ofjthis form within 30 days of completion of nmll
12.Well construction method: Rotary construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,1 Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: err 24c.For Water Supply&Injection Wells:
Also submit one copy of this form:within 30 days of completion of
13b Disinfection type HTH tt motor. well construction to the county h°ealth department.of the county where
constructed.
Form G W-1 North Carolina Department of Emironmeiitand.Natuml Resources-Division of Water Resources Revised August 2013