GW1-2021-08073_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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Chris 1Gng
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W'ellr Contractor Name t5lR R
3415 R fL
NC Well Contractor Certification Number S15 OIUTEil ASING'for mtilL psEd:+YillslOR•11N$R Ifa_` e)==
FROM TO DIAMETER THICKNESS MATERIAL
Green River Well&Pump fL R
Company Name 16-IiVNlrtt GilS1£iG OR Y fiBING �ma7 elosedr]
OQ I A FROM TO DIAMETER� THICKNESS MATERIAL
2.Well Construction Permit#: 1 ((•.'0< fLR
6 21 PVC
List all applicable we9permits r e.County.State,Yariancr,!r jedion,etc.)
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3.Well Use(check well use): ri: itsEly
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
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❑Agricultural ❑Municipal/Pubiic R
❑Geothermal(Heating/Cooling Supply) E IResddential Water Supply(single) R fL
❑tndustrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPI EMENT METKOD&AMOUNT
Non-Water -
❑ n- ter Supply Well: 0 & 20 fL Salvete' Mbt&Pour
❑Monitoring ❑Recovery & ft:
Injection Welh fL R
❑Aquifer Recharge ❑Groundwater Remediation '19..SAN1)1CRr1VEls PACK d. Ltatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIA L EMPLACEMENTafErHOD
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Aquifer Test ❑StonnwaterDraage R R
❑Experimental Technology ❑Subsidence Control
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❑Geothermal(Closed Loop) []Tracer FROM To DESCRWnONfed".twdnas,satlnwk ty L Mgr L ain sag eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R R
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4.Date Well(s)Completed: 7 S Well ID#
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5a.Well Location: R R
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Facility/Owner Name Facility 1139(if applicable)
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111:1 is AITA.
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Physical Address City,and Zip
_21.RBh1A'RKS - a
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 C e n:
(ifwell field,one[at/long is sufficient)
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SiJwfGe of Certified Well Contra Date
6.is(are)the we11(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 W ff Construction Standards and that a
7.Is this a repair to an existing well• ❑Yes or ®No copy ofthis record has been provided to the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the
repair under#271 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the bade of this page to provide additional well site derails or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For rmthiple injection or non-water supply wells ONLY with the same constmeven tar can
submit one form- SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: l I.5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferad(exornple-3@200'and 2@1003 construction to the following:
10.Static water level below top of casing: Y o (ft.) Division of Water Resources,Information Processing Unit,
Ifwmer level is above casing,use—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
U Well construction method: RDtary 24a above, also submit a copy of this form within 30 days of completion of Well
construction to the following:
(Le.aug—,rotary,cable,direct push
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24e.For Water Supply&Injection Wells:
HTH Also submit one copy of this form within 30 days of completion of
13b.Disinfection type Amount- well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Departmem of Environment and Natural Resources—Division of Water Resources Revised August 2013
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