GW1-2021-01297_Well Construction - GW1_20210329

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`FELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
ell Contractor Information:
;rant Mason 14.WATE 7AN
dl Scvnador Namc FROM TO DESORPTION
1254A a n.
rL (L
�-raell"Cenuactor Ce tificMion Numhe, Is,OUTER CASING ror.lmblti-md.arzlls OR LINER,if it Rubl!
LIN. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
PL n. 6 Is. .188 gals.
3a`�19a 16.INNERCA GOATUBING the and dined-lo,
ell Gmstrmetion Perndt a: / FROM TO DIAMETER I THICKKE.SS MATERIAL
r rahle Hell conn.arriml pamiv O-e-U1C,Coann'.Sate,l'a... ...arc l fL H. ho
ell Use(check well use): ft. R. In.
-'a ter Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESSI MATERIAL
-\c-tcuhural ©Municipal/Public n. [L In.
^"thee....al(Henting'Cooling Supply) )Residential Water Supply(single) R it. its
�IndustnalConmrercial ®Residential Water Supply(shared) 1/,GROUT
l"Railcn FROM TO MATERIAL EMPLACEMENT METHOD 6 AMOUNT
tiro-Rater Supply Well: ft li ft. I C C/ D b r-
Ji lanimnng Recovery ft ft.
^iectian R'ell:
fL Ft.
� gmfer Recharge QGroundwater Remediation 19.SAND/GRAVEL PACK Ve 1k661e
Storage and Recmen O$allltlt.v Banter FROM i0 MATERIAL I EMPLACEMENTMETHOD
tier 1eSt ®Slormwater Drainage fL ft.
i'.F>.rcrmmnial Technolmev ©Subsidence Control rL A.
(Geolhernal(Closed Loop) Tracer 20.,DRILLING LOG hatfach 6ddltlohal ih6eU-Kfseeesinu'
F
TO DESCRIPTION
(robq hudnm,,elVaxk nln slss ern.
;ceolhennal(Hearin /Coolie Return Other ex lain under 921 Remarks) n. - er-
')etc IN rills)Completed: - 2��Z Well IDA'iellLocntiam ft.Name Facility]Dq(if ePPliee6lq D.
1 f. C L1C752S n' MAR
Address.Cr and Zip Fir" ft. n.
f 21.REMARKS-: a -
�fGn1C( 't P....IIdentlfi=mrsNe (PIN) Used hardened steel drive shoe.
Latitude and longitude iu degrees/minutes/seconds or decimal degrees:
eII field.one l"derg is"411...at) 22.Certification:
36, 1137° 1 W a
'fare)the well(s)%Permetnent or QTemporan, Signmar,erCertified Well Contram, Date
9p signing dus form.I hereby cn,J) ,lm rLe r,,j command m accordance
this a repair to an existing tyelh ©Yes Or K©No „art 15A NCIC 02C 0100 or 15A NCAC 02C 0200 u',H C m naalorl 51,am,rds m,d mar o
a,,pair,fill oar Arlonu,.ell mnsrraafon informmfan and uplaln 01,Bowe of the cop)'of this rerord has been prodded to rhe,rtll m,•ner.
a.F-a21 rernnrRs ttpian m rvl rde hart of Uris term.
23.Site diagram or additional well details:
"ter Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
-nsln:c ,zo.mtly I (!W-1 is needed Indicate TOTAL NUMBER i Welk construction details. You may also arch additional pages if necessary.
I.e_ / SUBMITTAL INSTRUCTIONS
Total well depth below land surface: (�SS LL) 24a, For All Wells: Submit this form within 30 days of completion of well
­ahiple"ells lo,oil dglh,ydrffrr,nl(..ample-3 2001nrrd2©100) construction to the following_ y P
Static water level below fog of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
,'' teed a nbo,e cuing.r,,," 1617 Mail Service Center,Raleigh,INC 27699-1617
norehole diameter- 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
'.III[construction Method:
'7 �,y above. also submit one copy of this forth within 30 days of completion of well
_ F-fJ construction to the following'.
aiser.rots..cable,dims push.etc)
Uhision of Water Resources,Underground Injection Control Program.
_.'1R WATER SUPPLY WELLS ONLY: 1636 h1e11 Service Center,Raleigh,NC 27699-1636
-i idd(gpur) L Method of test: BIOW 24c. For Water Supply&Iniedion Wells: Inaddition 10 sending the form to
the address ot es) above, also submit one copy of this form within JO days of
Disinfection type: HTH Amount: 1 Ib' completion of well construction to the county health department of the county
-- where constructed.
:�+. North Carolina Depamerent of Environmental Quality Division of Water Resources Revised 2-222016