GW1-2021-08075_Well Construction - GW1_20211105

i
WELL CONSTRUCTION RECORD For tetanal Use ONLY:
This form can be used for single or
1-Well Contractorinfornlltton: f
Chris IGng K WAXrztnMs
FROM TO DT MON
Well Contractor Name R R
3415 & ft.
NC Well Contractor Catifimtion Number IS: Ofliems W
FROM TO DIAMETER .. .THICKNESS MATERIAL _
Green River Well & Pump ft. iL in.
Company Name ,1tic IPIlHF$CASINt73t 171B1N elnsed Y r x
2.Wen Conahvction Per FROM TO DIAMETER 1S MA11$tIAL
mit#: Z( � � ��®��� � ft. b0 ft' 6 'a 21 PVC
Lint aU applicable rtd/permitr(Lea Corny&aft Varwnm 1mfe�etc)
ft. iZ in
3.Well Use(check well use): 17°St3tEEN. r
Water Supply wen: FROM To' 1 DIAMETER SLOT SIZE I 119ICKNESS' IMA778BiAL
Agricultural ❑MunicipaMblic ft. ft.
❑ t�
❑Geothermal(Heating/Cooling supply) OResiaential Water supply(single)
❑Industrial/Commereial ❑ResidentialWaW Supply(shared) i&GRouz
FROM TO I MATERIAL EMPLACEMENT METHOD a•AMOUNT
❑ U It. 20 IL sakrete Mix&Pour
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. n
Injection Well: R ft.
❑Aquifer Recharge ❑GrormdwaterRemediation 'S19.SeWD/GRAVELRACK d e c
❑A fi forage and Recovery FROM TO
qmfer S MATERIAL very ❑Salinity Barrier EMPL+CENZNTMsi'aou
R. tt
❑Aquifer Test ❑Stormwata Drainage
❑Experimental Technology ❑Subsidence Control R
>30:D1tIt:1:lNGs1:QG:attach ad�tiouiit a6eets-rt ..'`
❑Geothermal(Closed Loop) ❑Tracer FROM TO DhSCRIPr10N(color,�aNnen,mluroct na,ere) .,.
❑Geothermal(Aeating/C-hri Return) ❑Other(explain under#21 Retnmjrs) p ft in tit 5 'i,
4.Date weu(s)Completed:i D �. Well ID# tt L4o % 5
It. 55- ft. S Vd
Sit.Well Location:
ft-
N i M KE P9� 55-" C S&
FaciliWOwm Name Facility MN(f Wplleable) �7
ft. ft.
b T;rit s f C)c1E R'D ft. '
Physical Adiftess,cay,and 25p
n
County Paroel identification No.(PIN)
Sb.Latitude and Longitude in degreWnrinutes/seconds or decimal degrees: 22 C eatioD:
(ifwell fieU,one lat/long is sufficient)
-7 2N ZJZ L
Ot 3 7 W 2iW Zs�
6.1s are the Swiatree of Certified Well co r Oft( ) well(s): ®PermaneTrt or ❑Te�rary By gg-V this jar s.1 hereby,eabfy that the meU(s)was 6vere)coinvueted m aoco,dance
with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 WeU Consruction Standards and that a
7-Is this a repair to an existing well: ❑Yes or ONo copy ojdhir record has been provided to the well owner.
Tjduis is a repair,fdl our k--wr/1 cmu t edon information and eaplain the nahrre ojthe
repair cruder#21 remark section or on the bast gfAis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wens constructed:_ construction details. You may also attach additional pages if nw sary.
For muffle infection or non-water supply wells ONLY with the snare eomdaotioq you can
m1 mit oneform. SUBMITTAL INSTUCTIONS
9.Total Well depth below land surface: 1 6`,7 00 24a. For Ail Wens: Submit this form within 30 days of completion of well
For mald'ple wells listaUdepths ijdffljn t(cuwWk-3Q200-and 2@/00') construction to the following:
10.Static water level below tap of casing: z UP Division of Water Resources,inforwtiion Processing Unit;
ljnater level is above casing,use 1617 Man Service Center,Raleigh,NC 276WI617
11.Borehole diameter. 6 (in.) 24b.For injection Wens ONLY: in addition to sending the form to the address in
Wen eonslzncHon �. Rotary 24a above, also submit a copy of this form within 30 days of completion of well
i a construction to the following:
( ger,rotary,cable,dmcet push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _ Method of test: /41r 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 IiWth department of the eotinty where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resomees-Division of Water Resources Revised AuZW 2013