GW1-2021-08076_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD For tr>�mat Use ONLY:
This form ear be med for single or merle wens
L well Contractor information:
Chris King I4 W)1$$$•2ONtiS. n yaCv v 's Ff:: a 1
PROM 70 DFSCREMMON
WeIlCamtraetarNuune It. R r
3415
NC Well CoUiractor Cer ifiwtionNumba SODiER.t'AhHN
FROM TO D 9
IAM87,t1t HtCKraw• MATERUL
Green River Well� Pump &
CampanyName :i6 t[J1V G13(1VGORTUBfN6 UL
. 1swtii, l'� rt
2.Well Contraction Permit#: .Z t 1 1 (7 1 1 +� PROM To DMI n rcn vtcxnt �L
List aff awh-able wupermas 0.-c wy sw,,A..,= ft 6 in. 21
hjetwoa,etc) PVC
3.Well Use(cheek well use): R R m
Water Supply Wen: I TO DrAMSrlSit sIAT spy 7HX3CN Sg MATSRlAL '"
❑Agncuttural ❑Mtnicipal/Public S e. m
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) tz tt m
❑Industrial/Commaeial ❑1Zesidential Water Supply(shamed) 1tt CRdl1T,
Ohrigattort
PROM TO SIHOD AMOUNr.'.
Non-Water supply well: 0 R 20 m• SakrEft MiX&Pour
❑Monitoring ❑Recovery ft R
Injection Wen: tz R
❑A9trifer Recharge ❑Groundwater Remediation 19 5AND7GgdV13d;psLg,f {
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM ft To MATtOMI. VKPrAt n1WT Mtr1HOn
❑Aquifer Test ❑Store water Drainage
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❑Experimental Technology ❑Subsidence Control Q f:
❑Geothemnal(Closed imp) ❑Traar 20 DRIGtii(Y6tbG aCtirliadddonia7rs�[`FROM TO D6S�II•RON o6, �y -
❑Geothesmal Heding/Cooling Return ❑Othec explain under 021 Remarks) R S
4.Date Well(s)Completed• 1 O/2 Z�y�II?f< R © tt d Sa Well Location: d r R
543
Facility/Owner Name R'
Fam%MO(ifapplimble) R S
kA S 1�'Vf l7°A y LS Rn
Physical Address,Cny,and Zip
CO—Y Parcel ldenti icationNo.(PIN)
5b.Latitude and Longitude in degreedminutedseconds or decimal degrees: '
(if welt field,one h bug is suffmiero) 22 Certi Man:
dS Z fo N 9 Z 19 S( W A> Z/
fell6.is(are)the wen(s): ®Permanent or ❑Temporary ofCertified WBy signiq this form,I that the wdl(s)wm,(wan)cmn&ueted m acwrdiowe
a and Cimmuchon stand
with 15ANCAC 02C.0100 or 15A NCAC,02C.0200 Wet! mds that
7_Is this a repair to an existing wdi: Oyes or lrJNo copy of this record has been previded to the well owner.
1f dds is a repair,fdl nut brawn well cmutruction i0rmaiion and aphrin the nature ofdra
Fgxur under#21 rwnwkr section or on the backofdusform. 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 c°°str°elect: construction details. You may also attach additional pages if newly.
Fornn&Vk injection or turn-watersuppty welts ONLY with die sane eo>�on.you curt
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: (It) 24a. For An Wells: Submit this form within 30 days of completion of well
For mukipde wells list aQ depths rf,:bffi tt(--We-3()a 200'ad 2®100) construction to the following.
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le.Static water level below top of easing: n, UP Division of Water Resoui ces,Information Ptuorasiug Unit,
Ijwater level is above Oasing use +^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. (rn) 24h.For Infection Wells ONLY: Tn addition to sending theform to the address in
Rota 24a above, also submit a copy of this fermi within 30 days of completion of well
12 Well construction direct
Rotary construction to the following:
firer,mWy,cable,direct push,etc.) ,
Division of Water Resource,,underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 106 Mail Service Center,Raleigh,NC 27699-16M
13L Yield(gpm) ` Z,. Method of test: Air 2,k.For Water Supply&Injection Wells
136 Disinfection type: HTH Also submit one copy of this form iwithin 30 days of completion of
Amount: well construction to the county health department of the county where
constructed. f
Form OW-1 North Cm0fina Department of Eummanent end Natural Resources—Division of Water Resour Revised August 2013
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