GW1-2021-01341_Well Construction - GW1_20210329

. . e;:Rlpt Fotrn"'
'.VELL CONSTRUCTION RECORD (GW-11 For lure noa]Use Only:
�
%sell Contractor Info nnatiom: - r LJC-4-49' 3� U
'_:rant Mason 14.WATE 7ANil
-11 Contractor Namc FROM TO DESCRIPTION
1254A 60 IL S n. _'C
ft. ft.
r'¢'dl-Centnaor Certification Number 15.OUTER CASING for.multltised wells OR LINER.RY' Huhli
1N. Poole Well & Pump Co. FROM 0 DIAMETER TIHCKNE56 MATERIAL
+ a 9 n. 8 in. 188 gals.
Va anre /. /l / 16.INNER CASING OR TUBING ,he theinul ed-loop)'
`.I ell Construction Permit H: lr w- OL��jQ/y-Z(-IGl FROM TO DIAMETER THICKNESS MATERIAL
pplrcahle well_ I' .limn porn...(r.e.VIC,County Sm.e banance,eKJ ft. 0. 1 In.
%ail Use(check well use): ftn. In.
`eater Supph1R'eile 17:SCREEN
_ FROM I To I DUMETER SLOTSILE I THICKNESS I MATERIAL
%Aenadmral ©Municipal/Public / A. rL c-/ in
'7eothermal(Heating/Cooling Supply) )Residential Water Supply(single) ft. a In.
%ptdusnial/Commercial Residential Water Supply(shared) 18.GROUT
lrr,Eauon FROM TO MATERIAL EMPLA EMENT METHOD&AMOUNT
'ml-Water Supply Weil! G fL ft. -,� �U�/
- It onitonn¢ Recovery It. ft.
`-'ieclion AYell:
fL
.quifer Recharge ©Groundwater Remedialion
FROM
SAND/GRAVEL PACK IfR Bnble
Aquifer$lOrage and RecOr'er5 �$a11111fy Darner EROAf i0 AfATERUL EMPLACEMENT METHOD
'Aquifer Test ©Stonmvater Drainage IT, n.
Frhenmemal Technology ©Subsidence Control ft. ft.
IGeolhemtal(Closed Loop) Tracer 20.DRILLING LOG fioftch 6ddlNoiul-shkw Ria"iaAa
FROM TO DESCRPTION nelor hsnl. q.nlr k nln du,de.
''('=_,thermal(Hearin Cooling Return) Other(explain under q21 Remarks)
- fL G�l fft. -�� GU I
"efe\fells)Completed: - G-Z Weil ID# fL 1 ft. r J
:.}Fell Location: ft aI n. -!i.
r J IT. ft.
(" ,,Name Facility lD(ifappliod,k) rt. ft.
fS`Ib0 Df/' 1c,1Ce fd ZehcJ16n /A<<775f a ft. t1 R Z02�
:c//al 4ddreas,Gty.and Zip IT. ft.
21r REAIAR$$.' -
Parcel Identification No.(PIN)
Used hardened steel drive shoe.
.Latuncle and longitude in degreeshrdnutes/seconds or decimal degrees:
ell field,one IeUlong is suf ,"'o) 22.Certification:
35. -7257331 N � 78304q-S 221
°+are)the nell(s)EK Permanent or 131fenrportu-3 Signature ofC,rfified Well Contrate, Date
Ay signing Mis form,I hereby cent pmr the ve0(s)n'art(vere)consnacod in accordance
->this a repair to an existing mall: 13Yes or ©K No r,,Ih 15A NCAC 02C 0100 or I NCAC 02C 02M well C,owo,limi 5landmd,and fhnr a
I gmir,fill ma Rnou1,yell corrarua ion u fonnmur and,,plain the nature of the copy of.hu record has been provided to the„'dl menu.
:ode.421 1em1,41 seal,,,m on pre bark q(,his faun.
23.Site diagram or additional well details:
'nr 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
-unmc}jon.onh, I GW-I is needed Indicate TOTAL NUMBER ofuells construction details You may also attach additional pages P riecesserv.
P ed l $UDMITTAL INSTRUCTIONS
fclot well depth below land surface: /15
(fld 24a. For All Wells: Submit This loon within 30 days of completion of well
- -vhip/r nrlh lh.n[I Aeppis rJ dr�rern lavample-3@200'and2Q100} construction to the following'.
Static,ea(er level below lop of casing: 20 ([L) Disisiou of Water Resources,Information Processing Unit,
oboe,ctouo,n,, 1617 Mail Service Center,Raleigh,NC 27699-1617
6nrehole diameter: 6 (in.)'' 1� 24b. For Infection Wens: hi addition to sending the form to the address in 24a
.'Yell construction method: �G/I-v / above, also submit one copv of this form within 30 days of completion Of well
rourv,ably dl,ed push, is co0ltmgion to the following'.
Division of Water Resources,Underground Infection Control Program,
'In iNATFR SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
_Yield(gput) Z O Method of test: Blow 24c.For Water Supply &Iniectiou Wells: In addition to sending the fort 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 constmaed.
- North Carolina Dupmratu l of Environmental Quality-Division of Water Resomca Reeised 2.22-2016