GW1-2021-08066_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Chris King FROMMOOATEg2bN
FR TO DIsSCRIP'T10N
Well Contractor Name ft. ft.
3415 fL rL
15"OUTER CASING for malfi cased.'
NC Well Contractor Certification Number
welb.OYtEDiER da Tik`=
FROM TO DIAMETER TffiCKNFSS MATERIAL
Green River Well & Pump ft. &
Company Name 16 �ASING:OR`'Tt1BING cfased loo'INNER'6 _ 377777
I �� FROM TO - DIAMETER TIUCKNESS MATERIAL
2.Well Construction Permit#: ,� 1 Q-3 6*1 0 i R fL 6 in 21 PVC
List all applicable well permits(i.a.Cormry,Stole,Variance,l jection,etc.)
fL fL
3.Well Use(check well use): 17
Water Supply Well: FROM - TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Mimicipal/Public tl. fL in
❑Geothermal(Heating/Cooling Supply) RIResidential Water Supply(single) ft & to
❑lndustrial/Commercial OResidential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri ation 0
JFL Non-Water Supply Well: 20 IL Sakfett: Mot$Pour
& EL
❑Monitoring ❑Recovery
lojection Well: R &
❑Aquifer Recharge ❑Groundwater Remediation 32,SANDICRAVE,PAC X-fifiiiplit t11e ;1ui in
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD`n
& ft.
❑Aquifer Test ❑StormwatcrDrainage ft. ft
❑Experimental Technology OSubsidence Control
'.20:DRIGLHYG':Lt)C_attach_addiriorialshcet�,R:-' � `j ;.:.ir` _`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(mloy hardness,soirlroek tyM grain sae,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft- ft, R 't,
fc ft 4.Date Well(s)Completed: Z� Lj Well ID# ft. ''�
w+V-
Sa.Well Location: ,
ft. R
GAmEaoN BFiL1K16- 15 D ft. ft. ,
F
a
c
ility/ow
wnner
�Name! ,��t�'' t Facility lDfl(ifapplimble) R ft
T� 887 `MFIA 2 H 1Llr Lv r fL IL f
Physical Address,City,and Zip 21 itElNAitfCS �`= �
N r'..N�FJf1�oNNUV b 2021 '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees:
g ) 22 Certification:
(ifwell field,one IaVlon is sufficient
35 23 y Z N QI'L 2 Z P W _ V
2
tif6ture of Certified-Well Co Date
6.Is(are)the well(s): ®Permanent or OTemporary By signing this form,I here b}certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Staminrds and that a
7.Is this a repair to an existing well: OVes or ElNo copy of this record has been provided to the well owner.
If this is a repair,fill out known well constnrction information and explain the naurre of the
repair under#21 remarks section or on the back ojthis jonn. 23.Site diagram or additional well details:
You may use the back of this page',to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLPwith the same construction,you can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 0 J (ft) 24a. For All Wells: Submit this.form within 30 days of completion of well
For inuhiple uvils list all depths if dierent(example-3@-700'and 2 a@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
p
11.Borehole diameter: 6 (in.) 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:
(i.e_auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) Method of test: Air 24c.For Water Sappy&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 Reurised August 2013