GW1-2021-08061_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For internal Use ONLY:
Ibis form can be used for single or multiple wells
1.Well Contractor Information:
Chris King .�.a�:����tzurrl�s
FROM TO DESC JMON`
Well Contractor Name R R 4
3415 f 11
NC Well Comractor Certification Number .'15 M—R` G fog miDIAMIEeil ieYls OlM201ER it= b1E`
FROAf TO DIAMETER lIIICKNESS MATE'aisr.
Green River Well&Pump ,z & ini
Company Name ¢9`�� 1 llV1VFRl1gIN2)R_3 UB1NG otld closed too` __J,
ZO i Z l/,`L i i FROM TO DIAMETER THICKNESS ESS MATE PVC
2.Well Construction Permit#: ft 0 ft- 6 id
List all applicable well permits f.e.Corm?;State,Variance,Injedim%etc.)
R R Iis
3.Well Use(check well use): 17cCREEN.
Water Supply Well: FROM TO I DIAMETER sLOTsIZE TIIICKNEss I MATERIAL.
❑Agricultural OMtmicipaVPublic R i-
❑Geothermal(Heating/Cooling Supply) aResidential Water Supply(single) & ft uL
❑lndustrial/Commercial OResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENr MEIAOD&AMOUNT<,
01rrigation
Non-Water Supply Well: ft' FL Mot&Pour
R R
❑Monitoring ❑Recovery
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 19;SA37D1OAAVEI PACK da W liable
,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPIACEMENi'METHOD
❑Aquifer Test ❑StormwaterDrainage R &
❑Experimental Technology ❑Subsidence Control
z20ibRI6IM0
I:0
R:aifaFJiadditiorialsheets' "` t77
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCREMON(color,harderst,swl/ry ktipe,grarin Am,etc
- R `'
El (Heating/Cooling Return) ❑Outer(explain under#21 Remarks) 5� tJ
4.Date Well(s)Completed: _/�y - Well IDf# ��ILSa.Well Location:
Facility/Owner Name ,_ Facility Off(if applicable)
PtP 191 �. & R NOV 202
>t
Physical Address,City,and Zip
Cormty Parcel identification No.(Pill
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifies' ,
(ifwell field,one lat/long is sufficient)
-_3 23 3 7- W
SiumZm- of Certified Well Contractor Date
6.Is(arc)the weil(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weft Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO 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}21 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
&Number of wells constructed: ( construction details. You may also attach additional pages if necessary.
For multiple hVection or non-water supply wells ONLY with the some constradlon,jmu can
submit one form SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: IUIC) —(JL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a depths if different(example-3@200'and 2@100 construction to the following:
10.Static water level below top of casing: ((L) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 010 24b.For Iniection 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
IL Well construction.method: Rotary construction to the following: f
(ie,aubrer,rotary,cable,direct push,etc.)
Division of Water Resources,CUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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_ HTH Amount: well construction to the county health department of the county,where
constructed.
Form GW-1 North Carolina Department of F.m ironment and Natural Resources-Division of Water Resources Revised August 2013