GW1-2021-01264_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.W'ell Contractor Information:
RONNIE STANCIL 14.WATER TONES
Well C.umieto[Name Most to DESCRIPTION
2283-A 0 x. 40 D.
fe 580 n.
.NCR'ell Contractor Certification Number 15.OUTER CASING for.!!L tweed welk ORLINER If a tieabk
GRADY POOLS WELL CO INC PROM TO DIAMETER TIIICK'ESS MATERIAL
p rt. 31 ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING InthermJ elwed-too
2.W ell Construction Permit#: FROM TO DIAMETER THICKNESS VIATER"L
Leo r11 apphmh/e we//uonsvunnan penmr,h e.I K (lnmD.Suite. I'...... etc) ft. ft. in.
3.W'ell Ise(check well use): "' ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIASETER SLOT SIZE THICKNESS I MATERIAL
OAgricultural ❑Municipal/Public ft. rg in.
�:!Geotheonal(Heating/Cooling Supply) ❑Residential Water Supply(single) f. ft. in.
Clndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑Irrl ation ❑Wells 1100 OO GPD FR0:11 TO MATERIAL EMPLACEMEWNHETHOD&AMOUNT
Non-Water Supply Well: 0 n. 20 " reAOSBENTONITE GRAVITY
ElMonitoring ❑Reco,ven
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa Drable
❑Aquifer Storage and Recoven ❑Salinity Ranier FROM To MATERUL EMPLACEMENT meTxoD
Aquifer lest ❑Stormwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑'Tracer 20.DRILLING LOGetteth tddidondeheets it neteeee
CGeothermal(Heatin 'Coolin Return) ❑Other(explain under 021 Remarks) Pam) TO DESCRIPTION color hsrdntn.wiL' Ektr o min surer.
0 fL 2 re TOPSOIL
4.Date Well(s)Completed: 2/2/2021 Well ID# 2 !E 31 f'' CLAY
5a."ell Location: 31 "' 640 h- GRANITE ROCK
FIBELIUS FOREST LLC
Facility.Ow re,Name fncdity ID-(ifapplicable)
192 MELS MEADOW DR. FUQUAY
Phi veal Address.City.and Zip ft. ft.
N/IAI �� 21.REMARKS
Connor L Parcel Identification No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if,61 field,one let/long is sutTicient) 22.Certification:
N N' Aeg4tu,2 2/2/2021
6.Is(are)the well(s): nPermanent or 13Temporarr Signature of Certified ll'ell Connactor Date
8,ngtung then Porrrt I hereh,reru);That the ue11(.,)vav(,Fuel eon,tn.etal m aemrdone,n'uh
7.Is this a repair to an existing well: ❑Yes or MN'o /$A,h'(M 02(" 0]00 or 1jA NCO(-0'( (1200 Wr11 te,,trucoor..O oukt,1,and that a cop)'
If tht,Is a repro-,Ill out krlmrn yell conorunian infermanon and explain the nature of the e/11..reword ha,hero p,,o sa d to Jm vM-Ferr,.
repay under=2]remark,mnnnn ar on the hack nflhr../ortn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction into
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of,yells (add'See Over in Remarks Box).You may'also attach additional pages if necessanr.
drilled or'r 24.St BNIITTAL INS"FRIG-I IONS
9.Total well depth below land surface: 640 (ft.)
I'ormtdup/e aril,ltstrll depth,ddiryrrent(emm�ple-31,r2on'a,02 el0(r) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Ori W ginal form to Di,ision of ater Resources (DWR).
10.Static water level below top of casing: 20 (ft) Irih.m aran, r.Processing Unit_1617 MSC.Raleigh.INC 27699-1617
ll.rrzr/Fret r.ahave rn,vng.u,. - `
n
11.Borehole diameter.
6 (in.) ,- [-1j X �� 2(�L�24b. For Injection Wells: Copy toUWR, Underground Injection Control(Il1Cl
Program. 1636 MSC.Raleigh.NC 27699-1636
12.W ell construction method: AIR ROTARY
24c.For Water Supply and Open-Loop Geothermal Return st ells:Copy to the
ri_z.auger-rotary,cable,direct posh.etc.I county-environmental health department of the count)'where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DW'R,CCPC UA
13a.field(gpm) 4 Niemoa artist: BLOW
Permit Program, 1611 MSC,Raleigh.NC 2 7699-161 1
13b.Disinfection type: HTH Amount: 1 Ib.
Form Go,-1 North Caro bna Depanmem of Encirunmental Qunlip-Division of water Resources Revised 6-6-2018