GW1-2021-08062_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For lntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Chris Fling :1 .W zolY>s
FROM I TO I DESCRIPTION
Well Contractor Name ft IL
3415 &
NC Well Contractor CcMficafion Number `15"OOTERGt1S1Nti'foi ri ulti csstd yi]Lc OR 1XVER if
FROM TO DIAMETER' MECKNESS AATERIAL
Green River Well &Pump fL ft.
Company Name :.I&ANNat:- 'S1l11G:ORTUBING closed-loo
� �, FROM TO DUKEfElt THICKNESS MATERIAL
2,Well Construction Permit#:---�i���.: ��Q � fL i 6 in, 21 PVC
List all applicable well permits r e.Comely,Sate,Variance,L jection.etc.) it ` io
3.Well Use(check well use):
17cSCREEN:..
Water Supply Well: FROM TO DIAMMER. SLOTSIM THICKNESS RIATERiAL
❑Agriculttual ❑Municipal/Public fL ft. U
❑Geothermal(Heating/Cooling Cooli Supply) ElResidential Waters 1 & B' in.
( €/ ng uPP Y) Supply(she)
❑lndustrial/Commercial ❑Residential Water Supply(shared) IkGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Teri 'on 0 fL 20 B' Salvett Mix&Pour
Non-water Supply Well: fL ft
❑Monitoring ❑Recovery
Injection Well: & &
❑Aquifer Recharge ❑Groundwater Remediation 119 SAND/Gittit?)IL PACg da "6k
FROM TO MATERIAL EMPtACEMEN'rAIET11OD
❑Aquifer Storage and Recover ❑Salinity Barrier
❑Aquifer Test ❑Stormiaater Drainage fL fL
❑Experimental Technology ❑Subsidence Control
"sonxu:l:nvc Ioc(;.ttail additio,ILl'stieeis�if " ;� .
❑Geothermal(Closed loop) ❑Tracer FROM TO DFSLRnMON(rolcr,hmdne sm"U.och sae,eta)
❑Geothermal(Heating(Cooling Rum) ❑Other(explain under#21 Remarks) it / &
s ft fL
4.Date Well(s)Completed: Z.IWeB ID# & . 2 1Sa.Well Location: S /ft ,—
zcc�
'r ft R
Facility/Owner Name Facility M9(if applicable) & &
:7 09 6012 CA F it t ft f
Physical Address,City,and Zip
t 21 'REM14RKS
County Parcel Ide»uficationNo.(PiN)
5b.latitude and Longitude in degrees/minates/seconds or decimal degrees: 22 Ce ca'
(ifwell field,one[Wong is sufficient)
W I Q !i,`S N S Z Z I' t i W �� ?
Signature of Certified Well Contractor Date
6.Is(are)the weil(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)um(were)constructed in accordance
with 13A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under Q1 remarks section or an the back of this form. 23.Site diagram or additional well details:
You may use the back of this page Ito provide additional well 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 sane construction,}au can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: to� (fL) 24a. For All Wells Submit this;form within 30 days of completion of well
For rn dhPle wells list all depths if&fferent(exmnple-3@200'aynd/2@100') construction to the following:
It Static water level below top of casing: 1D (ill 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 0-) 24b.For Infection 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
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
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 Environment and Natural Resources-Division of Water Resources Revised August 2013