GW1-2021-08064_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form'can be used for single or multiple wells
1.Well Contractor Information:
Chris King w_wA�l�xZoi►�
FROM TO DESCRIPTION
Well Contractor Name & E
3415 IL JIL
NC Well Contractor Certification Number .I5`,U,I1TElYCASING foimalh cased=we0s ORLiNER'rf cable''
FROM TO DL1MEfF]t THICKNESS nfA7'ERIAI.
Green River Well&Pump It. fL
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Company Name 16iANNERCAS111tG04t=T.t}BflVG' thermsielase�loo'
�.. ,j FROM TO DIAMETER THICKNESS MATERNL
2,Well Construction Permit#: s1 (ZOf, �Q f it CL s its 21 PVC
List aR applicable well permits fl.e-County,Slate,Variance,Gjecrion,etc-)
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3.Well Use(check well use): 17 SCRBBN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS I n19TERM-1.
❑Agricultural ❑Mimicipal/Public 11. G' in.
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) fL & in.
❑Industrial/Commercial ❑Residential Water Supply(shared) vw-GrtOt1T r=
01rriga6ion
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U & 20 ft. sate Mbt$Pour
OMonitoring ❑Rewvery iL ft
Injection Well: fL ft
❑Aquifer Recharge ❑ roundwaterRe mediati-on 19-SANOGRAVEL]PACJC(ffi0pIi&bIefL
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATMIAL I EMPLACFME TMEr1rODlit fL
❑Aquifer Test ❑Stonnwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control
MDRILUNG'-LOG;aftkhaddi6oialsheetsif ue '
❑Geothermal(Closed Loop) OTracer FROM TO DESCREMON(color,hardness.soivroh IyVe,gcj'-size,etc) `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0ft- U ft D
R ft4.Date Well(s)Completed: ' Z Well 1D# +
B. "�
5a.Well Location: CL& iL
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& CL t 1 C
Facility/Owner Name Facility ID0(if applicable)
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Physical Address,City,and Zap 21:RE1►fARKS.'::` .•
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minotes/seconds or decimal degrees:
(ifwell field,one Woug is sufficient) 22.Ce lion: ���Q�' 7 f
3� u �� F J N 0Y'2 .t3 c W l` L/
gnatumofCertified Wei ntractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I ereby certify that the wells)rras(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing wel: OYes or ®No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill old known well construction information and explain the nature of the
repair under'21 remarla 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non r ater supply wells ONLY with the same constreecdon,you can
suubrnit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: YL) 24a. For All Wei Submit this form within 30 days of completion of well
For multiple urns list aAdepths#&f—t(example-3@200'annd 2@100) construction to the following:
10.Static water level below top of casing: 80 00 Division of Water Resources,Information Processing Unit,
Ifrrater level a above casing,use"1" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, 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.outer,rotary,cable,direct push etc.)
Division of Water Resources,i Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
131E Disinfection type: HTH Amount well construction to the county ht alth department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013