GW1-2021-01348_Well Construction - GW1_20210329

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only. '
I.Well Contractor Information:
Grant Mason 14.WATER ZONES
FROM TO [� — DESCRIPTION
`ten Conoador Name -
4254A 7
fL ft.
a well'Convanor Certification Number 13.OUTER CASING fob.mvlfl-eased wens OR LINER nA IlnbIF
N.W. Poole Well & Pump Co. FRan, To DIAMETER TIDCRNESR 11IMEAL
nraa,.'ame + " S p n 8 m. .188 galy.
Gr / q u/J / 16.INNER CASING OR TIEING there W doisin too
1 Well Co uslrue no it Permit#: L✓ /—/ FROM t0 DIAMETER TIIICKNE55 MATERAL
v c11 app(aable,nll carrv....1",P,ora,(Ce-VIC,Cmmq',State.I fiance.aa) fL n. In.
3,tN cll Use(check well use): H.
Water Supply Well: 17.SCREEN
PP FROM TO DIAMETER SLOT SIZE TIIICKNESS nATERIAL
-_ )Aeocultural E)MunicipaVPublic If. H. in.
,j)Geothemtal(heating/Cooling Supply) %Residential Water Supply(single) n. N. In
industrial Commercial Q Residential Water Supply(shared) 18.CROlff
l Irt IQTIIOn FROM TO MATERIAL EMPLACEMENT METHODS AMOUNT
1 Non-Water Supply Well: Q fL ft. O L f /-
Monitoring Recovery fL ft.
!Injection Well:
a n.
IDAquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK na Iktible
' Aqufer Storage and RCCntY(y J$allDlty'Barrler FROM TOI MATERIAL EMPLACEMENTMETROD
!Aquifer Test ®Stormwater Drainage fL n.
Experimental Technology ®Subsidence Control P. n.
Geothemtal(Closed Loop) ©Tracer 20.DRILL ING LOG fnach hddidomi sheets Hbeeesu
0
71Geolhennal(Heating/Coolin Return) Other(exlain under 921 Remarks FROM T fL Lq DESCRRTION toobr haNnrv,solVraKk Nn tlrt ate.)P.
� SG' I
1.Note Well(s)Completed: Well 1D# d. fL �13 P. S F.n
-a.Well Locatiom rL N G—lift- r,
a n.
e 3t o.ae,Namr Fa<wty lDa Brapphume> rL n.
I I ?- I L.Jil Vj(i%/ Dr, V-k< fbr�f /l/ )'IS S- fL n. 2021
'I IAIddress,City.and Zip f. "' I... -1 ,_.if''
�✓nIC{. 21.REMARKS
,. Parcel ldentificationNo.(PIN) Used hardened steel drive shoe.
3b.Latitude and longitude in degrees/mnu ites/seconds or decimal degrees:
.)sell field.one svicng 5�is suReu,w 22.Certification:
3(0 -Q 0 N --79162& 733 W P-4-j. � — i I s al
is(are)the well(s)O% Pernoment or nTempomrp SigriztureofCcoilied Well Contrater Date
9y signing thu form,1 hereby cnr/r Umr elm mdl(sl mas Pvrre)cnnsvuued in accordance
-,is this a repair to an existing well: ©Yes or R©No ,vlth 15A NCAC 02C.0100 or 15A NCAC 02C 02001Vd1 Construction Standard and that a
r„n,.a repair,fill mu krmwn,,ell rnnssrucfirer information and,,plain the nature cf the ropy o/this recordhas been provided re the r•ell onner,
cpmr under#21 remnrks senior,or mt the back of rha form.
23.Site diagram or additional well details:
r.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
constmcQon,only l GW-I is needed. btdicate TOTAL NUMBER of wells construction details, You may also anach additional pages if necessary.
dulled I T� SUBhllTTAL INSTRUCTIONS
?.Total well face:depth below land sur LI 0-/ (ft-) 24a, For All Wells: Submit this form within 30 days of completion of well
'� mu0ipb rcel6liv all deptlinfd//nenr[emrnp(e-3@200'ned2@7a1001 construction to the following.
10.Static water level below'lop of casing: 11-0 (ft.) Division of Water Resources,Information Processing Unit,
,,,,ne.lei•rl if,,boar casing.me 1617 Man Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
p above, also submit one copy of this form within 30 days of completion of well
-2.Well construction method: ! constrnerom t0 the following
_.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnO Method of test• Blow 24c.For Water Suooh'& In action Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 1 lb. completion of well construction to the county health department of the county
where constructed.
ci Gt'-I North Carolina Department of Environmental Quoin-Division of Water Resources Revised 7-22-2016