GW1-2021-00350_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD Fo Imemal sat oNLv:
This form can be used far single or multiple wells
1.Well Contractor Information:
Ronnie Stancil 14.WATER ZONES
PROM TO DFSCRPTION
Well Contractor Name U ft v fL y�
2283-A ft. I ft I Vf
NC Well Contractor Certification Number IS.OUTERCASING for mald-cuedwells OR LINER(if. Ilcable)
PROM TO DI.UfETFA 'i—HL SS MATFAIAL
Grady Poole Well & Pump Co., Inc. o
• 186 �/v,
Company Name 16.11NNERCASINC OR TUBING fi,eothentent elased-loo
160887 nest TO DtAM t'El THCIOVFSg MATERIAL
2.Well Construction Permit M: V V U rL a in.
List all applicable well permits(i e.County,State, Variance,1 jecton,etc,)
ft fc in
3.Well Use(check well use): 17,SCREEN
Water Supply Well: PaoM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
OAgriculmral OMunicipal/Public a ft,
CGeothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft. ft In'
❑Industrial/Commercial OResidential Water Supply(shared) I&GROUT
PROM TO MATERLAI, EMPLACFMENT METHOD&AMOUNT
OIrrigation
Non-Water Supply Well: 0 20 f0 Portland& Gravity
OMonitoring ORecovery ft ft. Screenings
Injection Well: ft O.
OAquifer Recharge CGroundwater Remediation 19.SAND/GRAVEL PACK an '.bit
FMPIACEMFNT METHOD
OAquifer Storage and Recovery ❑Salinity Barri PROM er fL TO MATERIALit
❑Aquifer Test OStorrnwater Drainage
!L fL
CExperimental Technology OSubsidence Control
20.DRILLING LOG attach additional aheeb ifnecnu
OGeothennal(Closed Loop) CTraecr mom To I DESCRVTTOn come harmw WA eh type, ruirds,ete.
OGeothennal(Heating/Cooling Rem ❑other ex lain under 421 Remarks) 0 ft `L rt Topsoil
//' 2 fL Sir ft C /Q
4.Date Well(s)Completed: .ZdH Well IDN /
So.Well Location: rl' D R �aU fL i0 p C�
ft ft.
Roger Johnson
rt a
Facility/Oweet Name Facility IDd(ifapplimble) ft. ft
612 Driver Rd. Middlesex 27577
Physical Address,City,and Zip
21.REMARKS
Johnston
County Parcel Idendficanon No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
Qfieell Geld,one lat/long is sufficient)/
N w Tegof"' �tZ+LC�GY. 11J� ,W,fti'
Signature afcirofied Well Contractor are
6.Is(are)the wefi(s): ©Permanent or ❑Temporary in gIA signing this Oren,1 hereby certify that the welts )
LL t Rn' R f Y JY (/war(were)1 c in accordance with f SA NCAC OIC.0/00 or!SA NCAC fl?C.02p7 Well Consrruaues ion Standards and that a
1
7.Ia this arepair to an existing well: ❑Yes or BNo � ropy oJrhis tamed has beenpravidedmrhe nell owner.
Ifdeis is a repair,fill our known well construction Information and explain the nature of the
repair under d21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number wells constructed: One construction details. You may also attach additional pages if necessary.
For multiple injection or norvwater supply welt ONLY with the sense ronsnattlon,you can
submitoneform. 11a SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Jdrlerenr/example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: / (ft) Division of Water Resources,Information Processing Unit,
lJwater late!is above mnng,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniectou Wells ONLY: In addition to sending the form to the address in
Air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i_a auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
/ �CCj7
13s.Yield(gpm)� Method of test: Blow 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount: 1 Lb. well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Depamnent of Environment and National Resources-Division of W ater Resources Revised August 2013