GW1-2021-08089_Well Construction - GW1_20211105

WELL CONSTRtiCTION RECORD
This form can be used for single or multiple wells For Internal Use ONLY:
I.Well Contractor Information:
Chris King 14. ZONES
FROM TO DESCBIPTION
WellComractorName � � 0 �
3415 2 &
NC Well Contractor Certification Number 35;OUTER'CASAHG for'multi ca'sedwells plt!y1NER`fia ble`:
Green River Well&Pump Fit011t TO DIAMETER THICI�NFSS MATERUL
R. 2 in,
Company Name 16ANNER:CASING OR:TUBING 6theroist claised-ioo
l f ) o r � ) � q 14 iy FRont TO p1AMErER TUICKNFSS MATERIAL
2.Well Constriction Permit#: I (t5 Lam)l ^1 C/k �, ft 6 io.
List all applicable xe0 permits(i e.Count;State Variance,Injection•etc.) 21 PVC
3.Well Use(check well use): fl & in.
17:SCREEN -
Water Supply Well; FROM TO DIAMETER SLOT SIZE THICKNESS aATERIAL
❑Agricultural ❑MunicipaMblic R ft m
❑Geothermal(Heating/Cooling Supply) FIResidential Water Supply(single) ft & in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) `18.GROtff
❑Irri tion FROM ft.
bATERIAL ••EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 20 ft Salvete Ma&Pour
❑Monitoring ❑Recover}, it. ft
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation '19.SAND1GRi�vELPACI,,tfa``licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL ENiPLACEafE I'ME HOD
❑S
❑A uifer Test ft. ft
q tormnater Drainage
❑Experimental Technology ❑Subsidence Control & ft
❑Geothermal(Closed Loop) ❑Tracer lor,budges,su'Uraek FROM TOO DESCRDrri011i F-DRII1iIlVGOG:(attaetisdditioYMONets(coifneeessa
type,ZrAill siM ern
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) D ft '� ft- lqt
4.Date Well(s)Completed: Li -Z Z 1 WcB ID# ft Z ft- i� Qr>nctly
5a.Well Location: Z• fL F 'XV -t
ft. ft
ONL V i Q 4��A
tz ft.
Facility/Owner Name Facility IDN(ifapplicable)
ft &
Physical Addressr�City,and
nZr�p 1 -
I r�t�,�lt7Y�► <21..REMARKS -
County
Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce etion:..
N 9)Z 7.3 t 1, w .. ;
Si ture of Certified Well ,tor Date
6.Is(are)the weB(s): ®Permanent or ❑Temporary
By signing this form,I hereby certify that the xcll(s)xm(we-)constructed in accordance
7_Is this a repair to an existing ive1L ❑Yes or Ohio con,
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weft Construction Standards and that a
copy oftlus record has been provided to the well owner.
If this is a repair,frB out known well construction information and explain the nature ofthe
repairumder=21 remarks section or on the back ofthisform. 23.Site diagram or additional:well details:
1 You may use the back of this page to provide additional well site details or well
F Number of wells constructed:
For mrdnple it jedion or non-water supple wells Oft Y with the same constrrUlan,you can construction details. You may also attach additional pages if necessary.
submit one form, SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: ( ) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deprhs ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: I'd (ft) Division ollWater Resources,Information Processing Unit,Ifwater level is above casing,rise"+" 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
Rotary24a above, also submit a copy of this'form within 30 days of completion of well
(Le Well construction method.auger,rotary,cable,direct push,eta) construction to the following:
(i.e , ,
Division of Water Resources,Underground Injection Control Program,
FORA ATER SUPPLY WELLS ONLY: 1636 Mail Service Centeir,Raleigh,NC 27699-1636
13a.Yield(gpm) ® Method of test Air 24c For Water Snppl♦&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 health department of the county where
constructed.
Form GW-i North Carolina Deportment of Environment and Natural Resources-Division of Water Resources Revised August 2013
I ,