GW1-2021-01344_Well Construction - GW1_20210329

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only
I.1Yell Contractor Information:
Chant Mason 14.WATER 7AN
tt ell CbnVaaor Name - re061 TO DFSCRD'PON
4254A 'a ft. ft.
Ap IL 2 q( A.
'tC tfelfConvaaor Cenificetion Nwnber 15.OUTER CASING(formultl<uedweDs OR LINER Ua'-ileable
N.W. Poole Well & Pump Co. FROM TO DIMIETER THICKNESS MATER AL
+ rL SU ft. 6 tn. .188 gal...
—,ran.game Gun f�2ti9d�_2�� Y 16.INNER CASING OR TUEING ""mdelowd-last
L R'ell Construction Perudd 7/: FROM TO DIAMEFER I THICKNESS I MATERIAL
is all applmahle well'an s...........omi(s lLe.u1c.Coast Sta. .Variance,I'll.)
3.o,ell Use(check well use): fL n. In
15'ater Su Ip Well: 17.SCREEN
pP FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
IJAen,chural []Mumcipal/Public n. ft. in.
Geothermal(I{eaGngKooling Suppy') Qc Residential Water Supply(Single) R [L In.
-1Indusnial/Commercial [)Residential Water Supply(shared) 18.GROAT
i Inl anon FROM TO MATERIAL EMPLACEMENT 61EII10D R"FOUNT
i Nan-Water Supply Well: p rL 20 n. 1e 1 0�
Dlomlonng Recoven fit. n.
I Injection Well:
rL R
F)Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Ra ilcetle
(�,\glrl(ef Storage and RCCUVPr)' ®$aINIy Banner FR061 TO MATERIAL EMPLACEMENT METHOD
_jAquil Test �StonnwalerDrainage R A.
DExperimental Techlwlogy ®Subsidence Control fL n.
;�'JCieolhennal(Closed Loop) Tracer 20.DRILLING LOG batoich idditlthal Stella if baessa'
l Ge011tentla (H¢alln 'CCU In RCIOm) Other(explain under 421 Remarks FROM TO DESCRITTION cob,6Wn caNmak �Ln alu etc.)
IL J fL U. 1SCI
!.Date Well(s)CompkAed: C L 7 Well IDM fL fr' /��nL
3a.Well Location: lit-( IL 3O!{ n. Gf., -
C LIo Zs� rL n. -
��
aorbq-Owner Name Facility IDN o l'applicable) R n' 21
j l9 �f vas a V-Key C:( Via,I+JJt ]- 27a07 ft. n.
FL n.
Aaares,city.andzip
W I 11.REMARI(S
mint. HC-` steel drive shoe.
ParulldcnlifiWistN. (PIN)
Used hardened
-h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i melt Geld.rueliqladlong is sulfidew) 22./Ceeertiification:
N �. r U ' I T I l/ W
:.!,Care)the well(S)O% Permanent or ©Temporar}' Sigmnue UCCerclf¢d Well Convex for Dale
By signing this form,I hereto confy that the wells)was(were)constructed in arrordance
i.is this a repair to an existing well: []Yes or ©X No with 15A NCAC 02C 0100 ar 15A si 02C.0200 Wdl C•onmuction Standards and that n
,e a repair,fill out knmm well ronsnurtiou information and explain the nature of the tho cllhis rtrord has been pow,ded w the w,11 awn,.
under N21 r,n irk,ovum,m n,,die hark of t4is farm.
23.Site diagram or additional well details:
'd.For 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
mnstruclon.only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessar}'.
_!gilled SUBMITTAL INSTRUCTIONS
:'.Total well depth below land surface: O M-)
.....h, le,�e0,l,c.ffde me, dt .(e,,ua 10 coat For All Wells: Submit this form within 30 days of completion of well
p p / Jferor p 3rCU]00'arrd]�aJ/00') construction to the follmving.
i0.Static water level below lop of casing: /V (ff) Division of Water Resources,Information Processing Unit,
..oar to-!is anove ra,ing,n.e 1617 Mail Senice Center,Raleigh,NC 27699-1617
-1.Borehole diameter: 6 (fn.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submft one copy of this form within 30 days of completion of well
l2.Well construction riblo, method: canslrucifon to the following.
- auger.rotary,cable,direct push,do l
Division ofWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
131.7"laid(gpna) S^ Method of test: Blow 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
t 36.D onisinf,di I)pe: HTH Amount: 1 Ib' completion of well construction to the county health department of the count)'
where constructed.
:'Gtt'-I North Carolina Deparnnenl of Environmental Quality-Division of Water Resmuces Revised 2]]-2016