GW1-2021-08071_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RF RD For tmaaaI I ONLY:
ibis form can be used for eiroe or muhiple wells
1.Well Contractor Information:
�T�;N'ATIiltS7AN$S
Chris 1(ing mom TO DZSCRWMN
Well Contra"Name & R
3415 t: &
NC well Contractor Certification Number :Li _ iCABQdG-tbe` ' iieHt O$' ;iEfi t
FROM TO DIUMVIE'ER MUCRNSSS MATERIAL
Green River Well&Pump & R JUL
Company Name 16�EILIBB`EASIIVG#KFTt)IaIIVG` `
PROM TO I DIAMgrM Tummultm •..MA.'lIIt1AL
7-well Construction Permit#: 2 Q I ZO i T-© 3 Z I �� 6 rm 21 PVC
List all appbicabk well permits(Le.CaanttV.aft ya a—r 1/y-*an,etc.)
& ft in
3.Well Use(check well user 17N.. 3
Water supply well: FROM To n>!►MgrsR swr s s AN
❑Agricultural ❑Municipal/Public & R JUL
❑Geothermal(Heatmg/Cc oling Supply) ElResidential Water Supply(single) fL ft m
❑IndnutriaVCommercial ❑Residential Water Supply(shared) lsscltOtfc :'
_ FROM TO MATERIAL EMPLAMAENrMg1AOD&AMOURr
❑Non-Water Supply Well:on 0 It 20 Sakrete Mix&Pour❑Monitoring ❑Recovery R. R
Injection Well• fit- S
❑Aquifer Recharge ❑GroundwaterRemediation 19'SAND/GRAVgL'PACIC eta
❑Aquifer Storage and Recovery ❑may Barrier FROM Ta MATERUL EMPIACEMFxr MEMOD
R ft.
❑Aquifer Test ❑StoffiwaterDrainage ft R
❑Experimental Technology ❑Subsidence Control
�24D1211.YAVGiY`iOC atiaehadrTitneoilsbbebif„' ', �;.:;
❑Geothermal(Closed loop) ❑Trace mom
TO DI�r1oN eder,4udnm,saNrwk dG
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (} ft 3 R Tel �o r
4.Date Wens)Completed• Z7 21 Wen ID# -3 R /� i+ C. C a
Q a.Well Location: /O a. 2 & rc c,( a l 4--
51_
Fmility/OwncrNam Fecrlity1D#(ifspplimble) S R
2>r�1 404.►dl O fL >: F I ', '_ i J
Physical Andress,City,and Zip
-
County Parcel IdeutificaflonNo.M V
2021
Sb.Latitude and Longitude in degrees/minotes/seconds or decimal degrees: 22.Certification:
(ifweU Sell one latl ong is so8'icimt) ' -
N w l '-2 7-2
sngnaeme of Certified wen Date6.Is(are)the wel](s} ®Permanent or ❑Temporary
By sigrdng dun fosm.I hereby tx 16 that the WCH(s)was(were)consduded in accordance
with 15ANCAC 02C.0100 or ISANCAC 02C.0200 Weil Consirwan n Sta ifiv*and day a
7.Is this a repair to an existing well: ❑Yes or Me copy of das record has beer prvWded to the well owner
lfd-is a repair,fUowk--web camtrudion s4wmatkut andepkas the tudure qrthe
repaw wder#2l remarks sedwn a•an dte baatof tlbsfam 23.Site diagram or additional well detaili
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 muhVk i y'edion or non water supply we&OAr%YwA dw saute cargo you can
submit oneform. t SUBMITTAL INSTUCf10NS
9.Total well depth below land surface: ` (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For muWe wells lid aAdWft if&ff~(etaample-3®200'and 2®100) suction to the following:
10.Static water level below top of casing. 2.p ( ) Division of Water Resources,Information Processing Unit,
lfwaterkvd is above cesft use"+^ 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Mettion Wells ONLY: I 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
(ia-*-.ramny,cow dimrt posh.etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699LI636
139.Yield(gpm) i Method of test Air 24c.For Water Supply&Injectio I Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: HTH Amour well won to the county hen Ith deparu rent of the county where
constrtxxed.
Form GW-1 North Caroline Depmtrnennt of Envinnumc t and Nalmal Resources—Division of Ware Resources Revised August 2013