GW1-2021-01342_Well Construction - GW1_20210329

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use/Only:
ai ell Contractor Information:
Grant Mason 14 wATe PqN
ell C'unacr Name FROM TO DESCRIPTION
'1254A 1 aOrL a n.
/L 1L
:c t,ilrConuacmr Certification Number 16.OUTER CASING fot.lnhltl•Eaaed.we%s OR DllYEA Va"Iiuple'
LW. Poole Well & Pump Co. FROM TO DIAMETER iI11C%NE85 MATERIAL
�nlpany Name + a 3 n. g In. IN gals.
_ � Vj L p'y 1 16.INNER.CASING OR TURING ILrnul Elaeed•lou"
-',ell Construction Permit N: I� �] r �� Qt� FROM TO DIAMETER TgICKNE55 F1AtERUL
nil npphcable �ell corsua¢rim,Parris fie.VIC,Cannot,State,rmiance,end fL n. In.
5S'ell Use(check well use): IL R. In.
,,tcr Supply Well: 17.SCREEN
- FROAf TO p1AMETER SLOTSIZE THICKNESS MATERIAL
-?t\enadtunl ©Municipal/Public ❑. fL in.
'Geothermal(Heming/Cooling Supply) Residential Water Supply(Single) R. IL In.
'IndustnaliCommercial DReSidentual Water Supply(shared) 18.GROUT
I'In 12atl0n FROM TO MATE IAL EMPLACEMENT METHOD a:AMOUNT
'flan-Water Supply Well! IL aO R.
_jislrnlil0ting Recovery 0 r
ry ft.
Injection Well:
ft N
-
\quifer Recharge []Groundwater Remediation
.19.SAND/GEAVELPACK J viable
`'Aquifer Storage and Recovert [3Salinity Barrier FROM i0 MATERUL EMPLACEMENT METHOD
\quifer Test [3Stonnwater Drainage ft R.
Esperinental Technology ®Subsidence Control fL R.
[Geolhennal(Closed Loop) E)Tracer 20.:DRll.LINC LOG'.ot6ah lddllloiul iblerl VReceeba
—'Ge016ertna (I leafing/0001❑ Relum Other e% IRIn Under N21 RemaflCS FR(O�M Too DESCRPTI (r or M1udn IoNrock Inalee eIs.)
'lnte Wells)Completed: a� �-i WellID8 Z IL
Lo ft.
1�`((A'ell Location: It./ t� f R.
Z r'r- P rL H. q
--.nlir:O.rnu Name PaeilitylDN(if eppinie�eb(le) fL D. 021
Ul,d IN
1,11 Add,,,City,.and Zip J Is. ft.
21:REMARKS:'
- Parcel Identification No (PIN) Used hardened steel drive shoe.
_Ladrude and longitude in degrees/minutes/seconds or decimal degrees:
1 field,one Iat/lOng is suffcienr 22.Certification:
35. 01a7-73 N -'R • 649soS W a j 2 0 a 3 a t
=tv e)the aaell(s)®Permanent or Temporary Signature of C,ni6ed Well Contra for Date
_ Oy eignlag nhb Jorm,l hereby cr,,V�dvo the,rdl(a)vas Qvere)constructed in accordmue
s this a repair to an existing n'ell: []Yes or ©% No Mth 15A NCAC 02C.0100 or ISA NCAC 02C 0200 Well Construction Standards and that a
., a rcpaic fill run ka,,,o vrll cmovucr&a information and explain the nature a(d,e copy cf aus record has been provided to the,tell mvaer.
_..,under a21 remmks section or run the bacAoJrlds form.
23.Site diagram or additional well details:
'ar 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 teell
—n9mc(jon.only) GW-I is needed. Indicate TOTAL NUMBER of wells conslructiondelails. You may also attach additional pages if necessary.
Cad
)—{0 y SUBMITTALINSTRUCTION
pols list art de
TbIRI well depth below s il qdn rrnt lemnlple-3Q2oo'and2Qlpo')d surface; (fL) 24a. For All Wells: Submit this Conn within 30 days of completion of well
- n,dniplr„rna construction to the(allowing:
56
'.StaHc wafer le.el below lop of casing: (ft.) Division of Water Resources,Information Processing Unit,
nrtr level it abme casing.u.m" 1617 Mad Service Center,Raleigh,NC 27699-1617
-.Borehole diameter: g (in..) 24b.For Injection Weds: In addition to sending the form to the address in 24a
".'.i'ell construction method: I�P r 111 Ss above, also submit one copy of this fern within 30 days of completion of well
..eager,nary,cable,direa push,ac) construction to the following:
7R WATER SUPPLY W DiasIon of Water Resources,Underground Injection Control Program,
GI rIs ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
_'i field 1gpnQ I a— Method of test: Blow24c.For Water Supply&In'ecli n Well : In addition to sending the form to
- HTH 1 It) 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.
-I Nonh Carolina Department of Environmental QualiN-Division of Water Resources Revised 2.22-2016