GW1-2021-01349_Well Construction - GW1_20210329

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WELL CONSTRUCTION RECORD(GW.1) For Internal Use On^llsyN- ^ Qn. �� }'
%',ell Contractor l nformaliom: . . - r .,�,Y)f/IA12-11L ,�(
Grant Mason
_ 14:WAI TANF
eII C^ntraaor Name FROM TO DESCRIPTION
I254A o a 36L5 n. S
-- IL L
`,l'elI'Conuador Certification Nmnher
15.OUTER CASING foF,tAblH=rasellf"Us O U RLINER itR ' ubR'
LIN. Poole Well & Pump Co. FROM TO DIAMETER iI11CRNFSS MATERIAL,
e + a L n. 6 m. .188 gals.
arr [[ q 16.INNER CASING OR TUBING The clu rmal ed-lao'
''•ell Construction Per mil At: IT�' l/����f-/— zIJ) y FROM TO DIAMETER TRICKNFSS MATERIAL
. afrl¢ahle n,,cnmlrrmrinn p,rmrr l4-G9C.Counn'.Smm.Varlanca uc) P. n. In.
''?'eII Use(check well use): f. n, In.
''�'a ter Supply Well: 17;SCREEN
- FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
`,Agnrulmral ©Municipal/Public n. fL in.
.e"thennA(Heaong'Cooling Supply) a)Residential Water Supply(single) n. rL In.
11nrlu<tnaPCommercial QResidenhal Water Supply(shared) 18.GROVI
j litigation FROM TO MATERIAL EMPLACEMENT METH OD G MIOUNT
'1mr-Nate,Supply Well: !/ ft. 7,Uft. r10
_fit lon n l tone Recovery V. ft.
Le
;owrtion SV'ell:
-A uife,Recharge fL R
9 R Groundwater Remedialion
<
'.ipulfet Storage and Recover DSalinity Barr 19.SAND/GRAVEL PACK ifa Bubl
Banner FROM To MATERIAL EMPLACEMENT6IETHOD
\dui for Test D$tormwaler Drainage fL ft
Espenmenlal Technology ©Subsidence Control M n.
_11jervttermdl(Closed Loop) Officer 20.DRILLING LOU lift additional sheet6Qi,eeeRa'
STHiem,al(Heatin 'Coolin Return Other(exlain under 921 Remarks) FROM To DEscRlrrlON(aewr buane,,aNraeN nm uu,,a.
0 fL a n. SG, C
'`ate Weil(s)Completed:C ' Z 1 Well JD# ft ft. C&
1'ell L,J/ocatiioon:
are F 5 1rf`
Y
�. n,.n•r Name Facility lDM(ifapplisable) R n. -
S: G� tA/ l �(r4 .7'� i'vlt.�Y L7/ �klrr'9�r A/C rL n. 9 2�2�
. s_1:IdltCity.andZip
1'A21.REMARKS kit 1
I� Used hardened steel drive shoe.Parcel Identification No (PIN) t
.L.atimde and longitude in degrees/minutes/seconds or decimal degrees:
acid.one Iat/k.g is auffic"ro 22.Certification:
35•�S5o2 N -'1g.51623� Wa j3 - z
tire)tire welfs) x©Permanem or ©Temporary 51goanae of Certified Well Contratar Data
Hp signing Jul fo.m,l llareb7 c,,r fy 1.1 Jrz meJ(s),.as(,.era)co iv,lirred in acrnrdance
this n repair to an existing well: ©Yes or [DNo ,,,In 15A N'CAC 02C.0100 or 15A NCAC 02C 0200 R'e11 Connrucrian Slnndards and Jral o
., upair,ffl nut knomrr..ell connrunion irtfon r.00ll and,,plain Jrt nature cf tlm copy of,hie record hm been provided to ih,adl owner.
021 remarks s,uiar m mr he hock of ilus form.
23.Site diagram or additional well details:
gym'Geoprobe/UPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or,sell
--nstmcyon.only I GW-I '$needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifneceMary.
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To SUBMITTAL INSTRUCTION
tal well depth below land surface: V (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
+nd,irle n die h,1 alt depilre,f differan r„a,opr,-3@200'and 2@1 pD7
construction to the following:
`.Static Dater leael below top creasing: 6 (fly)rnsing Division Of Water Resources,Information Processing Unit.
' ,•'_,tr,rl is abme mr"_" 1617 Alai]Service Center,Raleigh,NC 27699-1617
Ilorehnle diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
". is construction method: a-fet r )e above, also submit one copy of this form within 30 days of completion of well
"at,.rotary,cable,dreCl push,ere.) construction to the(ollo,ving'.
WATER SUPPLY WELLS ONLY! Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
'i told fgptn) 5 Method of test: Blow 24c.For Water Supple& Inn lion Well : In addition to sending the form to
HTH 1 lb. the address(es) above, also submit one copy of this form within 30 days of
Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
"' North Carolina Deparmlenl of Envimnmonal Quality.Dieision of Wate,Resources Raised 2.22-2016