GW1-2021-08103_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
"Ellis form can be used for single or multiple wells
1.Well Contractor Information:
Chris King FROOMMRATFdtZONlr 5
F TO . DESCRIPTION
Well Contractor Name R R
3415 R R
NC Well Contractor Certification Number QS O1TEE1GC4rG-(far math eased A- ORi YER rf..a' aLle`"„
FROM TO DNMETFR 'IsrelavFss MATERIAL
Green River Well&Pump rL R
Company Name IINNERGASdVGOlttUBll�t':. elosedioo
EH-21001 FROM To DIAMETER THICKNESS MATERIAL
2 Well Construction Permit#: 1 M 160 fL 6 in. 21 PVC
List all appliaable vnell permits(i_e.Cmmty State,variance,Irgeuion etc.)
R R in.
3.Well Use(check wet!use): 17 scltlalSN
Water Supply Well-. FROM TO DIAl1 MR I SLOT SIZE THICKNESS IKATERUL
ft.
❑Agricultural ❑Mumicipal/Public ft. in-'
❑Geothermal(Heating/Cooling Supply) PIResidential Water Supply(single) R R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IR'GROUT'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNr
❑Irrieation 0 IL 20 R Salvete Mix$Pour
Non-'Water Supply Well:
R R '
❑Monitoring ❑Recovery
Injection Well: R R
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/CitAYEI:PACK rfa" IITe
❑A FROM TO MATERIAL EMPLACEMENTMETRODquifer Storage and Recovery ❑Salinity Barrier R R
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
21X DI ULING.LOG_attst�WdifioiiaPsheeis if n
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPrtON teebr,hardness,soilf s k type,giritin size,ete) +
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 20 R Red Clay'
4.Date Well(s)Completed: 1/22/2021 Well ID# 20 R 100 fL Sandy Clay and Water
100 fL IL Shale
Sa_Well Location: 155 fL 605 f` Granite
David Wagner R R
Facility/Owner Name Facility ID*(ifapplicable) R R
Holbert Cove Rd. R R
Physical Address.City,and Zip :RE$t.
Polk
Count' Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce c tion:
(ifweR field,one lati'long is sufficient ;
35 16 36 N 82 15 41 Z- 1 '
w
ure ofCertified Well Contra o Date
6.Is(are)the well(s): ®Permanent or ❑Temporary �.S f run h (�
By signing this form,I here cerri ,that the well(s)s was vrere conrtruded m accordance
with 1 SA 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 EINo copy ofthis record has been proiided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under'21 remarks section or on the 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
8 Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple h jection or non-water supply wells ONLY it-ilk the some cons&ucfion,you can
submit one forme SUBMITTAL INSTUCf10NS
9.Total well depth below land surface: 605 (ft.) 24a. 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@100� construction to the following:
10.Static water level below top of casing: 20 (g•) Division of Water Resources,Information Processing Unit,
If water level is abme casing,rise"+" 1617 Mail Service Center Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 20.For Iniection wells ONLY: iln addition to sending the form to the address in
24a above, also submit a copy of Phis form within 30 days of completion of well
12.well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163E Mail Service Center,Raleigh,NC 27699-I636
13a.Yield(gem) 2 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 county health department of the county wfiere
constructed.
E
Form GW-I North Carolina Department of Emironment and Natural Resources—Division of Water Resources Revised August 2013