GW1-2021-01459_Well Construction - GW1_20210329

`VELL CONSTRUCTION RECORD (GW-11 For lnte Pin alUseonly:
ell Contractor Information:
grant Mason . I4:WATER ZONES
ii r••nVactot Nasne FAOM1f i0 DE6CRH'PON
1254A
{a1 R
'V\/. nuaaol Coti6ell Number 15.OUTER CASING r0r,rim kaled.!"I"9R IdNER:RIP IV1
�.W. Poole Well & Pump Co. FRDM To DIAMETER THICKNESS 6ATERAL
�'alne
+ IL n. 6 ln. .188 galy.
..a„ rr ,, ` p e{ (�� 16..INNER CASING OR TUBING II rjgTU ed•Ibo"
ell Construction Permit 4:—1, w—c)�O L J" �V�y FROM TO DIAMETER THICKNESSI MATERIAL
. apphcahle nail mnsrn¢rion porniv(Le-U1C.County.Sala Variance.emJ ft. n. In.
11 Use Idceck w-ell use): ft. R. In.
'rater Supply{YeIL 17.SCREEN •.'...F
FRO61 TO DIAMETER SLOTSIZE THICKNF59 MATERIAL
rullural Municipal/Public n. fL In.
-.Tedhennal(Iieo llig/Cooling Supple) x)Residential Water Supply(single) ry, fL In.
- dustrral Conanemial Residential Water Supply(shared) 18.GROUT
tlrrlEaunn FROM TO MATERIAL EMPLACEMENT METH OD&MMUNT
^m-W'aiet'supply Well; r, ft. 1r� ft.
_J Plnmtorng Recovery `-1 R ��J ft.
'riectinn Well:
culler recharge R ft
g Groundwater Remedialion 19.SAND/GRAVELPACK L
\gwfer Storage and Recos'en [3Salinity Barrier FROM TO M1IATERI L EAirLACEMENT METHOD
-::rmfer lest [)Stonnwater Drainage ft. I ft.
iEq-cnlnental Technology ®Subsidence Control P. I n.
'-lenthennal(Closed Loop) E)Tracer 20.DRILLING LOG rtoeh additl6iulithean.ifhetealta"
C eolhennal(Uealin 'Coolie Return) nOther(explain under 921 Remarks) I FROM TO DESCR@1TON valor harts velV,xk rLn tlu era.
G rL ft. -
el
"ate Wells)Completed: to La(well ID# a R t. n. Q,1 pr,
veil Location: fL 1,
R n.
-- ' ^r�ner Camc Facili7[DO(ifappliceblel IL n. + '--
t 3 S' w 2 f-r fo .-,e- L...n n. n. i9, 2021
\ ..A<ss.C,i, and Zip ft. ft.
21.REMARKS:
Used hardened steel drive shoe.
-- Parcel Idemification N. (PIN) - '
1-i foudc and longitude in degi ees/minules/seconds or decimal degrees:
s fe!d.one laNlong is suf(icinnl 22.Certificalion:
35°`-idA�9.3`aNfp'kALAI �1. a�4" W
the well(s)OKPermaneut or DIremplarsirl Signature of Cern tied Wel l Cnntraror Date
his mgning rho/arm,I later,cerlav tlml he,rei!(r),gas(mere)c,n laird in accordance
this a repair to an existing well: ©Yes or OK No ,,,h l5AA'CAC 02C 0100 or l iA NCAC 02C 0100 11'ell C-nsvucrim,Smndards and rhm a
n rgmir,silIlow knm...n.11 rmutru,ran oybrrna,lon and eschur,henwa,e oJme copy of this record has been provided to tire uvil corner.
-- ,,,a2)ramits senion r.,n me back ojthoJanu.
23.Site diagram or adrliliopel well details:
er 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
'scuc(jon.only I GW-I is needed Indicate TOTAL NUMBER of wells construction details. You may also mach additional pages if necessary.
�e I
�L SUBMITTAL INSTRUCTIONS
*-list.veil depth below'land surface: S O \ (B.) 24a. For All Wells: Submit This form within 30 days of completion of well
ril it"all depthn7d,hreran fe,anlple-3@20o'and2©1Do) construction l0 the following.
_!alic,safer level below'lop of casing: Z� (ft.) Division of Water Resources,Information Processing Unit,
;e,•r 6 1617 Mail Service Center,Raleigh,NC 27699-1617
Bmehnla diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ll construction method: p
-;,•�^Y above, also submit one copy of this form within 30 days of completion of well
G construction to the following
srgvr.,oler..cable.direct push.elcj—� g
Division of Water Resources,Underground Injection Control Program,
-"?ll ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
field(gran) I l Method of test: Blow 24c.For Water Supply &Infection Wells: In addition to sending the form to
HTH
1 lb. the addresses) above, also submit one copy of this fern within 30 days of
Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
-i Norh Carolina Daparm¢nl of Environmental Qualln-Dicrsion of Wits,R....a... R,,ised 2 22 2016