GW1-2021-01268_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD For late.,]use ONLY.
Tlris fors can be used for single or multiple wells
1.Well Contractor Information:
Grady Poole Well & Pump Co., Inc. 14.WATER ZONES
PROM DES ON
Well Contractor Name 0 ft TO ft /
2283-A R. 1 0.
NC Well Contractor Cenificttian Number 15.OUTER CASING for mdu-rased wills OR LINER itu Or
FROM T DIAMETER THI S L
Grady Poole Well & Pump Co., Inc. 0 ft I V ft 16
Company Name 16.INNER CASING OR TUBING wTt e1mW400
160904 PROM TO DTANEI'F.R TIAC'KNESS MATfiaiii
2.Well Construction Permit#: R ft In
List all applcable well perears O.e_County,Sur e, Variance,Injection,orj
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIA.METElt SLAT SIZE TIDMNESS MATERIAL
❑Agricultural DMunicipal/Public It ft in.
❑Geothermal(Heating/Cooltng Supply) OResidenbal Water Supply(single) A. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 15.GROUT
MATE D AL MEIDOD&
❑Ui anon TO its Gravityi
Non-Water Supply Well:
[]Monitoring ORecovery
Injection Well: 7;ff,
ift AMOUNT
DAquifer Recharge DGroundwaler Remediation 19.SAND/GRAVEL PACK if go,Rcabk
FROM TO MATERIAL EMPLACEMENT MErulo
❑Aquifer Storage and Recovery []Salinity Burner ft ft
El Aquifer Test OStormwater Drainage
ft R.
DExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach addinonals6eets Lfnecessa
DGeothermal(Closed Loop) OTracer PROM TO DFSCR�'ON Icahn,hardvm soup it tope,crania sare,arc.
DGeothermal (Heating/Cooling Retum) ❑Other(ex lain under#21 Remarks) 0 ft it TOPSOiI
1/22/2021 ft ft.
Date Well(s)Completed: Well ft ft _
5a.Well Location: or
ft
Simon Elleston ft h.Facility/Owner Name Facility ID#(if applicable)
tt ft.
686 Sweetbriar Rd. Angier 27501 ft ft
Physical Address,City,and Zip 21.REMARKS
Johnston
County Parcel Ideatfieaton No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell Geld,one tat/long is sut5cienQ 1 ��j
N Wt Aearci2 'Stz CG 01/22/2021
Signature of Certified Well Connector Date
6.Is(are)the well(s): dPermament or 01'emporary lin v,p ing this form l hereby ce,OJ,tlmt the we/,'(cJ was(were/conrnvcted ui,send rice
with 15A NCAC 02C.0100 or 15A N(AC 02C.ONTO Well Construction Standards and that a
7.Is this a repair to an existing well: []Yes or ONO copy ojthls record has been provided to the well owner
If this is a repair,fill out known well construction information and explain the wrote of the
repair under#21 remarks section or on the back ofthisfimn. 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 of wells constructed: One construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same contraction,you can
submitoneform ry SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 16M i-C.L� X fxt)2 Qp� For All Wells: Submit this form within 30 days of completion of well
For mrdulale wells fist all depths tfdgerent(ample-3@200'and 20100') construction to the following'.
10.Static water level below top of casing: (ft) Division of W ater Resources,Information Processing Unit,
If water 1"I is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air Rotary 24a above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: construction to the fallowing:
oc.auger,rotary,cable,direct push ew J
Division of W,ter Resources,Underground Injection Control Program,
FOR WATER SUPPV WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: B1oW 24c.For Water Supply&IRieetion 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 GW4 North Caroline Department of Environment and banned Resources—Division of Waar Resources Revised August 2013