GW1-2021-01299_Well Construction - GW1_20210329

?YELL CONSTRUCTION RECORD (GW-11 For Internal Use Only. '
V,elI Contractor Informalion:
Grant Mason 14:. WN
ES
r ll rent/actor Name FROM TO DESCRIPTION
<t254A aQo a q 1 n.
fL fL
R'eII'Conuaam Certification Number
'A
FROMII&O TER.CASING fot.m DIAM ed.R .I LINER s XMAT
W. Poole Well & Pump Co. FROM TO DIAMECER THICKNESS aATERIAL
Name + ,L �� R• 8 m. .188 gals.
Froura EA CASING ORY'I DIAMETER
- lhereI Iclislim
_.'dell Construction Permit k: �� ..) LP�� FROFI i0 DIAMETER TAICRNE59 I MATERIAL
nil apphcahle rr'e!I cornm¢uon permits it UIC.Count_,Star.Variance,era') A. ft. In.
'.Well Use(check well use). fL ft. In.
`.-cater Supply Well; 17:SCREEN
-- \gnndmral [:)Municipal/Public n a FROM TO DIAMETER aLOT 511E THICKNESS MATERIAL
_ .;^otltennal(HeatinglCooling Supply) %Residential Water Supply(single) In.n. If.
't li)duItrirl Commercial Residential Water Supply(shared) 18.GROUT
111TIEa lion FROM I TO aA TER1AL EMPLACEMENT METHOD&AMOUNT
-',,,, 4Waler Supply Well: O !t.
i `
-J%lonoonng D Recovery fL ft.
'nleclio WWWII:
fL L
iAquifer Recharge ©Groundwater Remedialion
19.SAND/GRAVEL PACK
'Ayui far Storage and Recovery [)Salinity Banter Ka hind
FROST TO MATERIAL I EMPLACEMENT METHOD
,•:\ruder Test [)Stmrri Drainage
�E:penmcntal I echnologp [)Subsidence Control fL ft.
i')e,nirernal(Closed Loop) [)Tracer 20.DRILLING LOG kllaEh kdNXotui theendfile['- -
�(ie0thermmdl(lieatlll /Cooling Retum Olhere% lain under 921 Remarks FROM TO I DESCRIPTION reeler,hardnuSeolVrxk Ope,Uvra Am em.
0 n. -7 n.
i)ale Well(s)Completed: Well ID# 3 IL 30 m
,. 'fell Location: 7;o rL 3o 11 f6 r•.A: r . '. i -) -•
f. ❑. .. ...
-am..O..nv Name /II Facility Il(if applicable) IL n' ql
g9� {>k,n_t� 'r�nr_ffr1S{cn '�.1- (,OU-l5bu,fq n n.
,al AddrFs.Co,and Zip �� a n.
(--r—A k I,")
Parcel identification No (PIN) Used hardened steel drive shoe.
i, litude and longitude in degrees/minutes/seconds or decimal degrees!
ell feK one lot/long is sufficient) 22.Certification:
3�. Ilaaa� N —`18• a(0003o W � � _ la - a7
'('re)the wWu(S)[)% Permanenl or [)Temporary SigsntureofCeriified Well Cortator Oar,
By signing rhu form.I hereby certify war the wells)was(were)constructed in acrmda r,
�s this a repair to an existing well; [)Yes or [)R No with 15A NCAC 02C.0100 or 15A Ni 02C 0200 Neil Comrru,imn Standards and Thar a
•a repair,fill our krmun it construction information and,rplain the nature of ure copy oJthv record has been provided to the yell owner.
vnde 221 r, ru,k,,rcrimr or on the hock/this form.
23.Site diagram or additional well details:
or 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
-us:ntcljon.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessarv.
1-d
30 J1 SUBMITTAL INSTRUCTION
Cn1al well deplb below lend surface: (It•) 24a. For All Wells: Submit this form within 30 days of completion of well
nvnupn�rdo-by au deems/dgJrrerrr(rranrprr 3@20110,�•aand2@100'J construction to the following:
Static water level below top of casing: OD (ft.) Division of Water Resources,Information Processing Unit,
gar 1e�e/a above rasing.r,,, 1617 Mail Service Center,Raleigh,NC 27699-1617
3orehole diameter: 6 (in.) 24b.For Infection Well : in addition to sending the form to the address in 24a
•.well construction method: I O (-y
above,also submit one copy of this forth within 30 days of completion of well
auger,rotary,cable,direr push,etc.) construction to the following:
Dhishm of Water Resources,Underground Injection Control Program,
-)H WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center,Raleigh,NC 27699-1636
.Tield(Spin) 3 Method of test! Blow 24c.For Water Supply &Infection Wells: In addition to sending the forth to
HTH 1 lb. the address(ea) above, also submit one copy of this form within 30 days of
Disinfection Its Pe: Amount: completion of well construction to the county health department of the county
where constructed.
"`t' North Carolina Deformation of Environmental Quality-Division of Water Resources Revised 2-22-2016