GW1-2021-08118_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD For Internal Use ONLY:
?3vs form can be used mottipk well;
L Well Contractor Information
Chris King 14.WATF.RZ ES
FROM TO DESCRIPTION
WellcomractorName 7-1 Q R O R
3415 35-0 R 3i-5 R
NC Well Contractor CeniBcationNumber 15 OUTEVti SING terimaW e''wtdk:OR7dNSR
FROM I DLAP&Lr B IWCInHES4 MA777ttAL
Garen River Well &Pump R fL in.
Company Name >16.101NIMCASING OR"TUBING:
_ O �� FROM TO 11MMETER THICKNESS - MATERIAL
2-well Construction Permit#: R '0 R � is 21 PVC
List aAapplicable-Hpennds re.County Stall.Variance,hjeWini,etc)
R R is
3.Well Use(check Well use): j�arle>zFN
Water Supply Wen: FROM TO MWEroR SL-OTSM 7711CXNESS MATERIAL
❑��� ❑MtmicipaUPublic
R R in.
❑Geothermal(Heatmg/Cooling Supply) la Residential water Supply(single) f R in.
❑IndustriallCommercial ❑Residential Water Supply(shy) A GROt1T
FROM TO'.. MATERIAL HNPIACIa1tENT MEMOD&AMOUNP
Non-Water Supply Well: .:
❑ on 0 & 20 fL Sakrete Mbi&Pour
❑Monitoring ❑Reco R R
Injection Well: R R
❑Aquifer Recharge ❑Groundwater Remediation '19:SAMIGRAVEL PACE,[ bk
❑Aquifer StorageFROM TO MATERIAL EMPLACEMEKI'ME.TROD""
and Recovery ❑Salinity Barrier R R
❑Aquifer Test ❑Stormwater Drainage
R f
❑Experimemal Technology ❑Subsidence Control
20 DRILLING LbG!aftaetiaddihoaalaheeh if
❑Geothermal(Closed Loop) ❑Tracer FROM TO D N(mks,ladsev,m■ymek e�
❑Geothermal(Heating/Coming Return) ❑Other(explain under#21 Remarks) 0 t 10 R RE D elAA r'
4.Date Well(s)Completed: Z Well ID# 0 R Z R S igrV
59.Well Location: R 3 R C S HA L
., IL r +RC-7 PAW 7-
'r 1.-E-WW� AB IlllS LLC- R to ft. i;
Facility/Owner Name F—Tay 1D#(ifapplieabk) R R L R NOV _
►Ai�'�It Wc�lye7 �1A( R
Physical Address,City.and Zip 21:'REM4RKS
City Parcel Ideoti5cationNo_(PIN)
5b.Latitude and Longitude in degrees/tttinutes/seconds or decimal degrees: 2y Cewrti cation
(if weU field,one la llong is sufficient)
35 Lq tJ N ?Z 0 w
Signature of Certified Well C r Dale
6 Is(arc)the wdl(s� ®Permsnmt or ❑Temporary By signing this form !h terrify that the wou(s)was(were)eowcsaueted in aceordmrce
with ISA NCAC 02C.0I00 or I5A NCAC 02C.0200 WenCorueuctfon Standards and that o
7_Is this a repair to an existing well: ❑Yes or ®No copy ofthis record hoe been provided to the well owner.
ffdus u a repair,jV aid known well cauhudion information and explain the nature ofthe
repair wider#21 remarrts section or on the back of this fonn. 2&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 nutliple injection or non-water sgpply wdls ONLY with the saner car on,>m can
submit oneform. SUBMITTAL I NSTUCTIONS
9.Total well depth below land surface: b (R) 24a. For All Wells: Submit this form within 30 days of completion of well
For muktp/e webs the all depths ifdtrawd(=Rawple-3@200'and 2@1M construction to the following:
10.Static water level below top of casing I ZO (jt,) Division of Water Resources,Information Processing Unit,
If water level is above easing.use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (m) 24L For Iniection Welt ONLY: In addition to sending the form to the address in
Rota 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:
anger,rotary,cable,direct posh,etc.)
Division of Water Resources,!Undergtound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-16%
13a.Yield(gpm) Method of test err 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 where
constucted.
Form GW-1 North Carolina Depmtrnent of Envim.n.m.t and Natural Resources-Division of Water Resources Revised August 2013