GW1-2021-01616_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD(GW-11 FF.,Intemai Use Only
Well Contractor Information:
rant Mason I4.wATER 7014
�-11 Contractor Name FROM t0 DESCRDTION
1254A I H efffL- I Lt It. Z)_ �s C` 01
¢'eli-Comactor Cemir..tion Number ry" h
15.OUTER CASING fot,multl-eased.ana OR I:MER Uf"- ' bN
LIN. Poole Well 8 Pump Co. FROM TO DAMETER iHICRNF55 MATERIAL
Name + rL j V R g IR. .188 galy.
.,�„a If.INNER CASING OR TUSMG. hernial tlased•loo" '
.Fell Construction Permit R: FROM TO DIAMETER 1AICRNE33 MATERIAL
rll npplicohlr ur!/mrrunmtmn prnnita fi.r.VIC,Count,,Smrc.Yi rianc,,an, R n. In.
dell Use(check well use): fL R. In.
-Pater Supply Well: 17;SCREEN
FROM TO paMETER SLOTSIM THICKXF55 MATERIAL
_i.\etinrhuraI Municipal/Public R. f, in.
§Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) n. tt In.
-(Industnal,Commercial Residential Water Supply(shared) IS.GROUT -
_ §Im orlon FROM i0 MATERIAL EMPLACEMENT METHOD R AMOUNT
1'1on-Water Supply Well:
id.tonitoring Recovery it. O n• T
ejection Well:
?Aquifer Recharge ©Groundwater Remediation R R
Aquifer Storage and Recovers ❑$alinity Barrier19,SAND/GRAVEL PACK if iotaier FROM TO MATERIAL EMPLACEMENT METHOD
"Aquifer Test DStorm eater Drainage fL n.
Experimental Technology' ©Subsidence Control ft. n.
'Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG faftch additional shasaw If eebHA
FROM TO DESCRDTION eider,hoar eollhaek nda.r,.
Geothermal Heatjn Coolin Return) Other(explain under N21 Remarks t rL � n. . F .
3 ,
rule Wells)Completed: t S �� Well im Z R 6 o R C `l
'I ell`Location: �� h Lt0'-t n' C7 T'qn , T r•. r= ;•'; —: .,
cxT\C r
-ilia:Owner Name \ ` \ Facility 104(ifepplieebl ) R n. 021
L+ 1z� co.^nip 1..e.�.DI r•.Q r p R n.
1.si 1 4ddr ss,City.and Zip 1 , 21.RE
1���.1-• I FL
MARKS: 1 'd y i ,)it
,\ pa...II enni tionNo.(PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-.ell 0eld.one latlong is sdficienq 22.Certification:
35034'40e49& 71V4l '38.G70W 01�
r,are l I he weE(s)®R Permanent or ©Temporary Sigmtore of Certified Well Connator Date
_ Ry signing our Jorm,1 hereby cemfy,hot rice wells)was pvercl constructed in accordance
=this a repair to an existing well: ©Yes or A©No with 15ANCAC 02C 0100 or 15ANCAC 02C O2M ip,II C,n,nuctian 51,ndmd,and that o
'I 11te"I,fill ow krmun yell mrwrunion irfonna um and,,plain the rotor,f the copy of this record has been provided to the uell putter,
umier 021"omrke section or no the back ftho from.
23.Site diagram or additional well details:
Tor 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
'nstmcrn,only IGW-I is needed. Indicate TOTAL NUMBER of wells constructiondetails. You may also attach additional pages ifnecessary.
ed
i � lL SUBMITTAL INSTRUCTIONS
1
Total well depth below land surface: , � } LL) 24a, For All Wells: Submit this form within 30 days of completion of well
,mduple sins no all depth if different luanrple-3@20.00 old 26 Into I
fdd2@!00') construe'ion to the following:
'.Static water lerel below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
.a.1e,-r2s oho.....ing.ose 1617 Mail Service Center,Raleigh,NC 27699-1617
'.Borehole diameter: g (in.) 24h.For f rleclion Wells: In addition to sending the form to the address in 24a
..f- above, also submit one copy of this form within 30 days of completion of well
queer,rorery,cable,direct p h,
-.,'.fell construction method:ac) A r3'P.f f construction to the fallowing:
us
Division Of Water Resources,Underground Injection Control Program,
`)R WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
.'field Igpm) so Method of test: Blow 24c.For Water Supply&Infection Wells: 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
fi.Disinfection type: Amount completion of well construction t0 the county health department Of the county
where constructed.
va` Nonh Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016