GW1-2021-08079_Well Construction - GW1_20211105

6
WELL CONSTRUCTION RECORD Far hmmal use oNLY:
This form can be used for single or multiple wells
1.Well Contractor Information.
Chris Kin 14 WATElt2MES ., :..•,' ..
9 FROM TO ~DESCRIPTION
WcU Contractor Nam tt R
3415 R- fL
NC Well Contractor Certification Number ;15;OUTERCASIltIG(foezmd tasediidls):OR-1;II�iEit "ble)
FROM TO DUU1iETER THiCrQTM I MATERML
Green River Well$ Pump E. IL
Company Name 16INNERCASINGVIKU BMG ""thetmrtdosed=too'
2.Well Construction Permit#: 2,q Q p�J FROM TO DIAMETER TWCANESS MA7ERML
-_ (J I � ��/a d g 1O'�t 6 ft- 21 PVC
List all applicable well permits(i.e..County,State,Variance,b jection,etc.) ft.R
fL in.
3.Well Use(check well use): 17,SC1tEE1�T
Water Supply Well: FROM TO DUMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipalftblic ft. & in.
❑Geothermal(Heating(Cooling Supply) f lResidential Water Supply(single) fL ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri Lion Non-Water Supply Well: 0 fL 20 ft- Salvete mix&Pour
❑Monitoring ❑RecoverY H. &
Injection Well: iL fL
❑Aquifer Recharge ❑GroundwaterRemediation R19:-SAND/GgAVELPACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMIETWODfL ft.
❑Aquifer Test ❑Stormwater Drainage
R ft
❑Experimental Technology ❑Subsidence Control
-30,'11PJLIJNG;LOG.attathiiddititinal slietts if iiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRH'1'ION(mlor,ha.dnm%so;vork gpe,gritinsue,ere
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R• fL Y
4.Date Well(s)Completed:/7-I t-U WeI1 ID#
R &
5a.Well Location: fL
fa
&-arrte Our-io
R fL
Facility/Owe Name Facility IDf(ifapplicable)
yy ���r� ft ft
J---- 7
Dei 1. ✓r4.5 Or,
fL ft
Physical Address,City,and Zip 21 REbTARtLS
��n�e�san
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in d -;gi egrees/minates/seconds or decimal degrees: 22.Certification: •� -' " ' `"I
(ifwell field,one lat/long is sufficient)
35 l 23 N 8Z ZL-1 00 W
l2�I!-2dZo
Si of Certified Well Can- Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)it
(were)constructed in accordance
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ojthis record has been provided to the well owner.
ff this is a repair,fill out known well construction information and explain the nature of the
repair under-"21 remarks section or on the back ojthis form. 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 constructed: I construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,iwu can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_' 70.J (�) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3®200'and 2 a@100') construction to the following:
10.Static water level below top of casing: l DO (ft-) Division of Water Resources,Information Processing Unit,
Ifutuer level is above casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY:;in addition to sending the form to the address in
Rota 24a above, also submit a copy of ithis form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct posh etc.)
Division of Water Resources,lUnderground Injection Control Program,
FOR WATER SUPPLY'WELIS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Air 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 cotrnty health department of the county where
constructed"
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013