GW1-2021-08110_Well Construction - GW1_20211105

WELL CONSTRUE RECORD
This form can be used for single or gooMple vMb For Internal Use ONLY:
1.Well Contractor tnforimtion:
_ f
Chris King
1`-WAT&R7ANBS s
wellConhactarName FROM TO DffiGRIrl70N ' '
3415 R R
R R
NC Wen Contractor Cernfi Number 1-5OUTERCAMC, foimuNteasedwelte:4RLIIQK
Green River Well& Pump FROM R TOO DIAMErFR MATt�BiAl
R
Cody Nam in.
1G`IMAlt-CASING OR TUBING
2.well Construction Permit#: W Z 0 '� FROM To Dr�src rs_o
'iutcxN»s ty,��;
List 094WHeable well permits r et ft. FL6 in
�1:M�Yarrance,lrgechon,uc) � 21 PVC
3.Well Use(cheep wen an): R R is
Rater supply weeB: 17.SCRBEN ;
FROM TO SLOTS
DIAMETER IZE TIIIQ(N}Sq OAgricultmal OMunic" R R in. MATERIAL'
tpa!/Public
OGeothenmal(Heating/Cooling Supply) EIResidential Water Supply(single) fL R in.
❑lndusfrial/Commescial OReside ntiai Water Supply O I GROUT
Olrrion FROM,1011-w
+T EMPLACEMENT MCM011&AP40UNT
OManit tsr Sappty Well: R 20 R Salvete Mac&Pour
Monitoring ORecovery R IL
Injection Wel•
❑Aquifer Recharge
OGrotndwaterRemaediation DRl GRAp gft
dOquier$[Olg an Recovery OSeinity Barrie, FROM TO
O MAerT ERIAL
AquiferTest OStormwaterDtainge R HHPLACF211EN1 11tF'IA1 ~`
OExperimental Technology OSubside nce Control & ft
OGeothermal(Closed Loop) 20`DRI47:IPtC LOC OTracer atrAehaddihoriaCsh�If
OGeothe rmal Heating ennun Rectum) OM"Other( lam under#21 Remarks) Co? R R D a�oN(C,IW War laws y,ar
4.Date Well(s)Completed: r�T Wen ID# R --tt
52.Well Location: R IL
t ��5PP�1 STD E -R U
Facility/Owner Name R R
IW� Facility ID#(if applicable)- p R
Physical Address,City,and Zip R ft
21 RBMARI(S
Cotmty Parcel Identification No.(PIN)
Sir.Latitude and Longitude in degreWorinotes/
(if well fie seconds or decimal d
1d bUlotrg is sufficient) 22-C6*fication: i l.i'
7-5 2,1 N 02. 0(0 1 D w
6.Is(are)the wen(s).. OPermanent or OTemporary SiV—of Certified Well Contractor Date
By sitn g this form,I hereby certify that the wells)wos(wear)oo—ucted in accordance
7.Is this a repair to an-&ling well: Oyes or ONO with 15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Conrbrrction SY ljthis rs a frll out known raonstr,rerion information and esphrtn the,rattrre
wep copy ojthis record has beenprovided to the well owner: mdards and that a
repair ender#21 remmkrsection or on the backofthisfosm ofthe 23 Site diagram or additional well details:
&Number of weps constructed: ( You may use the back Of this page to provide additional well site details or well
For,mdVe i,#eW_or,mtr-water stP*wells ONLY;Wh the sm x co�aron details. You may also attach additional pages if necessary.
submit oneform, oonsriacSon you can
9.Total wedl depth blow land surface. SUBMITTAL INSTUCPIONS
For muLrp/e wells tart aQ depthr rfdrffernrt(esm„p!e-3®200•and 2 (fL) 242. For All Wedls: Submit this form within 30 days of completion of well
C��') construction to the following:
10.Staticcasing;
water level below top of
lfwater level is above acting;use^+» 00 Division of Water Resources,Information Processing Unit,
11.Borehole diameter. s
1617 Mail Service Center.,Raleigh,NC 27699-1617
rn-)
246 For 9999n wells ONLY: In addition to sending the form to the address in
i2 Well constraetioa mNhad: Rotary 24a above, also submit a copy of this foam within 30 days of completion of well
('e.eager,rotsry,cable,direct p�et,_) construction to the following:
EFORWATER SUPPLY WELLS ONLY: Division ofWater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
m) Mthdof test: Air 24c.For Water Sapaly&Injection Wells:
on types HTH Also submit one copy of this form within 30 days of completion of
Among well ructconstrrlCtiem to the county health department of the county where
constructed-
Form GW-t North Carotins Depmtrnent of E'MTOn nest and Natural Resoure.—Division of Water Resources
Revised Augatit 2013