GW1-2021-08060_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD For Interbel Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor larormation:
Chris Fling :I4 wA� zQi±it s
FROM TO DESCRIPTION
Well Contractor Name It. IL
I
3415 U- &
IS OiT4R GASTFtG tun;-multi®sedfcalls Y1R
NC Well Contractor Certification Number rfi 'lde"
FROal TO DUMEnit THICKNESS MATERIAL
Green Fiver Well&Pump n ;n
Company Name 16IlMNE)IICAStNG OR TU_B1NG ';closed loii'
7 t FROM TO uLVW ra•R THICKNESS MATERIAL
2.Well Construction Permit#: Z `1 2 ' It, O R 6 +a 21 PVC
List all applicable acid permits rie.County,State,Variance.Injection,etc.)
ff. R is
3.Well Use(check well use):
Water Supply Well-. FROM TO DIAMETER sL(rrsim THICKNESS I MATERIAL
❑Agricultural ❑MtmicipaMblic R It. in.
iEL
❑Geothermal(Heating(Cooling Supply) 011csidential Water Supply(single) ft R
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply well: •
❑ lion 0 IL20 IL Sakete Mb(&Pour
ft It.❑Monitoring ❑Recovery
Injection Well: & fL
❑Aquifer Recharge OGroundwaterRemediation ;14:SANU/GRAV>$1,.1'ACIC i€a 62eR
[]Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACEMENT METHODSalinity Barrier R ft.
OAquifer Test OStormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control
ZU 11113I.I.IIVGI;Of:.ait8e6 addrhomil'sheebifiacessamZ
'
❑Geothermal(Closed Loop) []Tracer FROM I TO DESCRIPTION keby budmss,smWI k type,pyk sbr,etc
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) Q fL j S i;
tt i
4.Date Well(s)Completed:Well ID# R [t
5a.Well Location: R R
Facility/Owner Name Facility 09(if applicable)
& R
Physical Address,City,and Zip
r V\��V■ tV�i`� � i Ai
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degreestniinutes/seconds or decimal degrees: y
22 Certi e
(dwell field;one Wong is su icient)
35- 23 37- N e2 ,Z 18 3 > W
SignatreofCertified Well Con I Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I here certify that"the well(s)was(were)constructed in accordance
with ESA NCAC 02C.0100 or ESA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing we1L• ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a mpair,fill out krtoam well construction information and explain the ordure ofthe
repair under r21 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
&Number of wells constructed: construction details_ You may also attach additional pages if necessary.
For mrdt/ple injection or non-water supply wells ONLY with the same construction,)rou am
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this'form within 30 days of complexion of well
For multiple wells list all depths ifdiff—in,(—Pre-3@200 and ZQI00'j construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above easing,sae"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 0-) 24b.For Iniection Wells ONLY: I In addition to sending the form to the address in
FOB 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:
(Le-auger,rotary,cable,disco past,etc.)
Division of Water Resources,IUoderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
`
13a.Yield(gpm) 10 Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: IiTM Amount-- well construction to the cormty health department of the county where
constructed.
Form GW-1 North Carolina Department of Emironment and Natural Resources-Division of Water Resources Revised August 2013