GW1-2021-08082_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
Thisform can for can be used for single or multiple wells
1.Well Contractor Information:
Chris King 14.\1'ATERZONES
FROM TO DESCRL TION
Well Contractor Name ft. ft.
v
3415 rt. It.
4
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased,!wSils)OR LPIER(if a &cable)
FROM TO UMNtETER THiCKNE,4S MATERIAL
Green River Well & Pump ft. ft. i
Company Name 16.INNER CASING OR 1'ttBING !rothermot dosed400
FROM TO DIANILTER I THICKNESS NIATERUL
2.Well Construction Permit#: 2_0100113 1 5 7- � ft. it 6 "' 21 PVC
List all applicable yell permits(i.e.Comm,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
]Water Supply Well: FROM To I DLI,NIETER I SLOTSIZE Till CKNESS t1aTERLaL
❑Agricultural D'MtmicipaUPublic ft. ft. in
❑Geothermal(Heating/Coohng Supply) 0Residential]Water Supply(single) R. ft- is 1.
❑Ind ustrial/Commercial - ❑Residential]]rater Supply(shated) I&GROUT
FROMTO \iaTERL4L EN1PLaCEMENTNtETHOD&ANIOUNT
\on-Wa
❑Non-Water Supply Well: O It 20 ft- Salmete MIX$Pour
ft. ft.
❑R�lonitoring ❑Recovery
Injection Well: Ito fz
❑Aquifer Recharge DGroundvmter Remediation 19.SAND/GRAY EL PACT (if a ticable)
FROM TO MATERIAL EMPLACEMENT NJM. 10D
❑Aquila Storing and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stommater Drainage
- ft ft•
❑Experimental Technology ❑Subsidence Control
Z0.DRII.LING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color.uardnes,soillmrp, ,eminsize.etc.)
❑Geothermal(Heating/Coohn_e Return) DOther(explain under 21 Remarks) ft ft. G L
ft 1l S 2'4.Date Well(s)Well(s) 1""W
l(s)Completed: j l ]\ell ID#
O ft 40
ia.Well Location:
ft ft
Facility/Owner Name Facility IDS(ifapplicable)
ERR;A;4LW iQ, RD. ft. N 0 V -Physical Address-City,and Zip 21.R£211ARtCS
I�i:�aFt�,So�
County Parcel Identification No-(PTN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Cer6fic • n
(ifwell field,one[at/lone is sufficient)
N Z. 14 Zo
Signature ofCenified Well Contractor Date
6.Is(are)the well(s): 01'ermanent or ❑Temporary Br signing this form,1 herebr certifi-tharthe u•ell(s)was(were)constnicted in accordance
With LiA NCAC 02C.0100 or hA NCAC 02C.0300 Well Co stntetion Standards and that a
7-Is this a repair to an existing well: ❑Yes or PJNo copt�ofthis record has been provided to the well ou-ner,
lfthis is a repair.Jiff out known it-ell consinictior it formation and explain fire nature ofthe '
repair under=31 remarks section or on Ilia back ofthis torn(. 23.Site dia%trttrr or additinnal well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constricted: construction details. You may also attach additional pages if necessary.
For inuinple injection or non-,rater srtpphy rrel/s ONLY it-ilk the same construction,i on can
submitonefornr. SUBMITTAL INSTUCTIONS -
i i
9.Total well depth below land surface; /y�0`I (ft.) 241. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdierent(example-3@200'and 4)400') construction to the1bllowin?:
10.Static water level below top of casing- )—to 00 Division of Rater Resou l•ces,Information Processing Unit,
Ifu-oterlevel isabore casing,use"-" 1617'Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection]Wells ONLY: It 1 addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
t'i.e.auger.rotary,cable.direct pusit etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636'Mail Senice Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) L 'Method of test: Air 24c.For Water Supply&Injection]Wells:
Also submit one copy of this form jtviihin 30 days of completion of
13b.Disinfection h•pr HTH Amount: well construction to the county health department of the county where
constructed.Font(G]1'-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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