GW1-2021-08111_Well Construction - GW1_20211105

WELL CONSTRUCTION RFr-ORn For hsernal use ONLY:
Pus farm can be used for single or multiple wells
1.Well Contractor Information:
Chris King 1L WATER ZONES
FROM TO DESCRIMON
Well Contractor Name R ft
3415 tz R
NC Well Contractor CeAifiwtmn Number
1&.0V CASIlr1G foE mullitsSeawd h ORI�VER
FROM iDI 1114ME7ER iutcK 1ESS MATERIAL
Green River Well& Pump ft. ft. aL
Company Name � .'16:1NNER:Gi13tNG:ORTUBIN!'='
V' FROM TO D1AMEM 17llCKNESS MATER AL
2.Wen Construction Permit#: pp�� �]u1 tz R 6 is 21 PVC
List all applicable well permits far County.State,varranc4 hyec*-%etc)
IL fl. is
3.Well Use(cheek well use): 17 SCREEN
Water Supply Well: FROM TO ,. DIAMETER SLOT SVE „THICKNESS.. MATFJUAL
❑Agricultural ❑MtmicipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) & tt m
❑lndustrial/Commercial ❑Residential Water Supply(shard) 1&GRtOUT ,'.
FROM TO MATERIAL EMPLACEMEN r METHOD&AMOUNT
01rri tion p & 20 K Sakrete Mix&Pour
Non-Water Supply well: ft. R
❑Monitoring ❑Recovery
Injection Well: S S
❑AquiferRechatge ❑GmundwaterRernediation ;19:SAND/GRAVEI'PACK ri"
❑ infer St and Recovery _ FROM 7T1 MAT IMIAL EMPIACONENT METHOD
Aq Storage very ❑Salinity Barrier
[]Aquifer Test ❑Stomwater Drainage fL ft
OExperimental Technology ❑Subsidence Control
24LDREUMCIAQ imachaddilibindsheetsif
❑Geothemral(Closed Loop) ❑Tracer FROM TO DUCRWMN cote, saW—k sew,ee�
❑Geothermal(Heating/Cooling Return) ❑Other(eacplain under Remarks
ft ft -RU
t
4.Date Well(s)Completed: Z1 WeL 1D# tt 8
tt ft .
fF—
Sa.Well Location: R S
0L ILI)r'A 1 ft ft
Faro*/OwncrName Facility Mff(ifamlicehle) -
`��) y S S �,� "
ft ft
Physical Address Croy,and Zip /i
21i REMARKS°.:.
�u��411'OfLt�
21
County Parcel Identification No.(P"
5b.Latitude and Longitude in degrees/nduates(seeonds or decimal degrees: 22.Certification:
(ifweff field,one h0ong is sufficient)
3 S 2 5 1 N 13Z. 0 LL—? YaW
Signature ofCertified Well Contractor pate
6.Is(are)the well(s): ®Permanent or ❑Temporary
By signing this form,I hereby aRify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction S tanAwds and that o
7.Is this a repair to an existing well• [Wes or ®No copy ofthts record has been provided to the well owner.
If this is a repair,full onus ibmwn well conawdion hybmmtion and explain the now*of the
repair under#21 smarts section or on the bark of thirfonn 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 multiple uyection or non-water supply wells ONLPwith the some constrwam,you can
submit one form. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: ft.) 24a. For All WeOs: Submit this form within 30 days of completion of well
For muhtple well;list all depths tfdl( —(—voe-3®200'and 2@100) construction to the following:
10.Static water level below top of easing: (B-) Division of Water Resources,Information Pry Unit,
lfwater level is above casing:use"+" 1617 Mail Service Center,Raleigh,NC 2709-1617
11.Borehole diameter: 6 {m) 24b.For IDjection Welts ONLY. In addition to sanding the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(ie.sugar,rotary,.able,duect push,etc-)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i`Z Method of test err 24c.For Water Supply&Injection Wells:-
Also submit one copy of this form within 30 days of completion of
131L Disinfection type: HTH Amount well construction to the county health department of the county where
constrnctea-
Form GW-1 North Carolina Delmatment of Environment and Natural Resources—Division of Water Resources Revised August 2013