GW1-2021-08099_Well Construction - GW1_20211105

WELL CONS=UenON RECORD
is form can be used for siriEle or multiple wells
Th For imemal Use ONLY:
I.Well Contractor-Inform tion:
Chris IGng 14.a azI;RR ZMES: .
_FROM i TO DESCVJprtoN
Weli connector Nary �� B. i� fL
3415 R R
NC Well Connecter Certification Number J&OUTER;CASMG i i-jii ihffk'pIt L1NER if
FRoli TO I DLaMEM THtCt1VFSS tdATERIA[,
Green River Well&Pump R fL ;a
C°mpao"Nmme 16INNERCASING_ORTUBING: _
- LOB i FROM TO DL1M£tER MUCK-NM MATER[AL
2.Well Construction Permit#: _ i fL R s M. 21 PVC
all applicable-u pe wits(ace comity 3Yate,variance:bg-ma etc) 1
R R is
3.Well.Use(cheek-well use):
Water Supply Welk FROM I To I D[AmE ER I sL rslzr I nt[ctSS M ATE Tt1AL
❑Agricultural ❑MunicipaMblic B' & 1O
❑Geothermal(HeatmgCooiing Supply) Mesidenhal water Supply(single) R R m
❑IndustialiCommemial ❑Residential Water Supply(shared) a8'CROUT ,-
iROa! TO. MATERIAL FAtPLACEM4NfME[RODdcAMOu r
Mitigation
Non-Water Supply Well: O R 20 D' 3alvefie wk&POW
❑Monitoring IL IL
Injection Well: & R
❑Aquifer Recharge ❑GroundwaterRemediation iiMSANDJGRAVXLMACHcd " >;
❑Aquifer Storage and Recovery ❑Salmtty Barrier FROM R To MATERML EMP1AM EMM METHOD
R
❑Aquifer Test ❑Stmin atmDraimge
❑Experimental Technology ❑Subsidence Control R R
20 DRII iaNG LOG..(attch adossT 'H' -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSI RWMN(+Nir numm .soivswx ` ermsmr.eii:)
❑Geothermal(Fleatjng/Cooling Rd=) ❑08ter(a Phdn under521 Remarks) D R
4.Date Welts)Completed i 2 Well IINJ 10
R �L' R V A
Sa.Weft Location: o R IL r- �i-Ji4Lk
Lao R .VL MMTE
Facilih! Facdia•IDA(ifaliplirable) t! R
R &
Ptnsic/al�Address,City:and Zip
1
i Jd ;21- ISMARKS
NOV - 202
Co�y Parcel -NOV
(m)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.Certirea#on: ,
+s ofCertifnxlWellCantractor pore
6.Is(are)the well(s)- ®Permanent or ❑Temporary
L?v.rrgriM Mora+,i hemk certifi thai the weA(s)ass(were)constructed m accord2we
with 15A NCAC 02C.0100 or 15A MAC 02C.0200 WeII Construction Srmafor&and that a
7.Is this a repair to an existing we& ❑Yes or 8No c'oM ofthir record has been provided to due urR owner
ifthis is a repair,fill ow known cull rnnunrction irfarnwrim and eWhria the nature ofthe
repair wider=`21 rewarks section or on ere back ofthisform. 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 wells constructed: construction details. You may also attach additional pages if necessary.
For nwhiple h0ixtion or non-crater surpptt weIIs OAZP with the mrae aonstradFai ym,can
submit one form. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: () (fL) 24a. For AB Weir Submit this form within 30 days of completion of well
Far mahiple wells list all depths if&ffe ent(amnrle-3@200'avid 2@100) construction to the following:
It Static water level below top of casing: 3 (D-) Division of Water Resources,Information Processing Unit,
If inter leml is abmv casing,use"-" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 6a.) 241L For Injection Wells ONLY: In addition to sending the form to the address in
.Well construction method. Rotary Rota Ma atmve,also submit a copy of this form Within 30 days of completion of welli.
(1e.now,tummy,cable,direct push.etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY\VELI S ONLY. 1636 fsUff Service Center,Ralejgli,NC 27699-1636
13a.Yield(gpm) 11 Method of test: Air 24a For Water Supply&Injection Wells:
Also submit one copy of this farm!within 30 days of completion of
13b Disinfection type I'lTM Amount vuell construction to the county health'department of the county where
constructed.
Form 0W-1 North Corolnm Depmiment of fsrtirone ent and Natural Resources-Division of Water Resources Rmised August 2013