GW1-2021-08059_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
Ibis from can be used for single or multiple wells
1.Wen Contractor Information:
Chris IGng
FROM To DESCRIMON
\Yell Contractor Name 8. -&Tp1.
3415 & J
NC Well Contractor Certification Number FWROF TIBt GAS G fo weDsj(3I�1;i NEIS ` AT AL
FROAI TO DIAMETER TltiCtaVESS MATERIAL
Green River Well$Pump ft. a
Company Name y (mot 1G IPav&R A90G ox:fllsuvG ;dual d�ob'
�1 ` Z®� V �� FROM TO GDIAMETER THICKNESS MATERIAL
2.Well Construction Permit& r ' ft t5 ft '° 21 PVC
List all applicable well permits a e.Cornay,state,Varimme.Injection,etc) is
3.Well Use(check well use):
Water Supply Well: FROM I TO ..: -I DIA ITE11 a,SLOT SIZE I THICKNESS_..- MATERIAL r
❑Agricultural OMtmicipaUPublic ti & ra
❑Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) ft ft. m
❑Industrial/Commercial ❑Residential Water Supply(shared) f&GitOFl3., ". r......:`h # ...;: sa -_ ,..
FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT'
01trigation 0 & 20 IL Salvers WE&Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: R R.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GililirPACg der'' hk :`
FROM TO MATERIAL EMPIACEAtENf METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
B R
❑Aquifer Test ❑Stormwater Drainage IL R
❑Experimental Technology ❑Subsidence Control
:10-31R1LLIlY(.=SSG;attactia�ditiniitshxtsil
❑Geothemal(Closed loop) ❑Tracer FROM To DESCRIMON(mler,has I saWreek q _etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 1 0 ft t fi� �P4 Pm
4.Date Well r s)Completed: I Well MN >z 14W 0 L-
Sa.Well Location: I
6 AM380 040N ft ft
Facility/Owner Name Facility 09(if applicable)
Jo ow 12at- RID,- ft ft
Physical Address,City,and Zip
N FNp'%C '1N3 �a:ttElvl�Rxs
County Parcel identificationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.C •it lion: 'KvLLJJiiev:1i<I I
(ifweR field,one Wong is sufficient) !i �,.,.,r t I I�
l
�J 22 iQ N �92 03 (Zf
Signature of Certified Well C Date
6.Is(are)the well(s): ®Permanent or ❑Temporary gt,signing this form,I here y certify that the weft(s)was(were)constructed m accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wefl Construction Mandards and that a
7.is this a repair to an existing well: ❑Yes or EINo copy of tins record has been provided to the well owner.
Ifthis is a repair fill out known well constntaion information and explain the nature ofthe
repair snider 01 remarks section or on dw 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
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple tryection or non-Crater supply wells ONLY with the saw construction,yar can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24a. For All Wells Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(—ple-3@2100'and 2@100) construction to the following:
10.Static water level below top of casing: �. (ft) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is abuse casing,use"+" 1617 Mail Service Center Ralei
gh,NC 27699-1617
I Borehole diameter. 6 (a) 24L For Infection Wells ONLY:i 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:
(ie-auger rotary,cable.direct pusk etc-)
Division of Water Resources,EUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Air 24c.For Water Supply&Injectio 1 Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount, well construction to the county h th department of the county where
constructed.
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013