GW1-2021-01298_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information: . . ' . . ' li�la�
Grant Mason .. 14.WATER ZON
tt'ell Contractor Name mom TO I DESCRIPTION
4254A 71 S FL 31 IQ R-
n fi
NC welfeontractor Certification Number15.O11TER:CASING(fot mbltl-rand.ireW:OR LINER:Va' Iktib'a
N.W. Poole Well & Pump Co. FROM i0 DIAMETER TNICKNESS MATERIAL
+1 n 1 �u3 a. 6 n. .188 gale.
'mnpaq'Name ` 1 l.9 V /�qf 16.INNER CASING OR
ru TUBING elaedaod'
2.Well Consume
lion Permit k: J Factor TO DIAMETER TAICRNEaS MATERAL
nl au applicable well corurrne'rian pe'r in(i.e.U/C.County.Sure.t9rianea,etc.) R n. in.
3.Well Use(check well use): (L D. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT aITE THICKNESS oIATERUL
Aencultural Municipal/Public R. ft. in.
Geothermal(Heating/Cooling Supply) )Residential Water Supply(single) R rL In,
Industrial/Commercial OResidentiai Water Supply(shared) 11.GROUT
I Irri ation FROM T�O 1 ATERIAL EMPLACEMENT METHOD a AMOUNT
Non-Water Supply Well: rJ FL OV h t Id UL/'
Monitoring Offecovery fL H.
I Injection Well:
Aquifer Recharge Groundwater Remediation a
Aq Recovery Q uifer Storage and RecoveSalini Bawer 19.SAND/GATO PAGKH -We
ft
I0tY FROM. TO MATERIAL EMPLACEMM
ENT METHOD
Aquifer Test E3Stonnwater Drainage P. R.
I Experimental Technology ®Subsidence Control fl R.
Geothermal(Closed Loop) ©Tmcer 20.DRILLING LOG.aaich additb sloarb If aecaht
Geothermal(Heating/Cooling Return) Olher(explain under#21 Remarks) FROM To DESCRIPTION issues,hardens,saturator de.
0 M1 �?- H' S41'1
J.Date Wells)Completed: I "S 1V Wall ID# '� R �7 b H.
^a.Well Location: �,[ fL >2 q H• G
Vu Lk r)wrfa_y rt n. Z1
ailin+Owns Name Facility]DO(ifappliuble) R N.
I�03 siZ /'1leA-L1X1R R� • �Ly,vl )lt� ,//L a n. I u:
/^-h � n
vsical Address,City.and Zip n ft. -
�k Yn,
Used hardened steel drive shoe.
Parcel Identification No.(PIN)
ch.Latitude and longitude in degrees/rninules/seconds or decimal degrees:
if well field,one laulong is sufficient) 21 Certification: •�y�
N -1r rJ319(o� ( W .�' / - / Pr-•-- 1. 5 - �- I
1.Ismael the uells)®R Permanent or Temporary Signature of Certified WeII Contra mr Dam
By signing no form,/hereby certify dear the aell(s)was(were)constructed in accordance
.is this a repair to an existing well: OYes or R©No with 15A NCAC 02C.0100 or 15A NCAC 02C 0200 IVeli Corr,.uoion Standards and tbar a
Of is a repair,fill out Anmrn well construction information and explain the nature of the copy a/this record has been provided to the Neil owner.
.pmr wide.921 remark,section or cause back of rho form.
23.Site diagram or additional well details:
'i.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
construciion,only l GW-I is needed. Indicate TOTAL NUMBER of wells constructiondetails. You may also attach additional pages ifirecessary.
drilled I r� SUBMITTAL INSTRUCTIONS
?."Total well depth below land surface: J (fL) 24a• Far All Wells: Submit this form within 30 days of completion of well
n.nvdtipVewe(h list nll depths/derem(e.mmple-3@100'and 2@l00') construction to the following:
10.Static water level below lop of casing: (ft.) Division of Water Resources,Information Processing Unit,
/,ewer lael is above casing,ose 1617 Mail Service Center,Raleigh,NC 27699-1617
(1.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
!
-het above, also submit one copy of this form within 30 days of completion of well
au'er construction method: y construction to the following:
it a auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground IHJecton Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.field(gptn) Method of test: Blow 24c.For Water Supply&Injection Wells: In addition to sending the form to
HTH 1 lb. the address(es) above, also submit one copy of this form within 30 days of
E3h.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Depertmem of Environmental Quality-Division of Water Resources Revised 2-22-2016