GW1-2021-01326_Well Construction - GW1_20210329

eVELL CONSTRUCTION RECORD (GW 1 a = flf ftlFh
For Internal Use Only: - -
. s:ell Contractor iafor-mation: . ,
Grant Mason
. . . .14:W ATE ZON -
ellContraetorName FROM TO DESCRUTION
1254A L 0 rL j n. Pyy)
rL fL
-;WeII'Conuacmr Certincation Nmnba
d.W. Poole Well & Pump Co. PLOUTERCASDi0 rot,meta�haad."lls;oRD1NER;ira-1k1m4 _
FROM TO DIAMEIER 7HICRNESS MATERIAL
Nar , + rL 1 d n 6 in. .188 gals.
PerultiDU L/$ 16.INNERCASINGORTUBINC. - Ihefsifit eloga lam"
- \'ell Cn BlraC time "n...t. !-- L V ✓7 FROM TO DIAMETER TFUCRNIM; MATERIAL
nil appncnhle..'ell convnrcrinn pennus p.e.U/C,Caunly.Sm/q✓ariance.ere) fL A. In.
'. sT'ell Use(check well use): fL It. In.
-Voter Supply Well: 11.SCREEN
IA¢ncullural FROM TO DIAMETER SLOT SIZE i111CRNF99 MATERI
AL
QMunicipai/Public ft. n. In.
IGeothermal(Heating/Cooling Supply) )Residential Water Supply(single)
� ROUT n. rL
Is.G In.
IndusriabConunefcial [)Residential Water Supply(shared)
llrtigalion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-1vater Supply Well: R 2 n. 4
4Nonitorin¢ Recovery R ft.rieclion R'ell:
_\Aquifer Recharge Groundwater Rm fl. fL
di°Aquifer Storage and Recovery DSahni Barrier 19.SAND/GRAVEL PACK Lif, eihle
--'Aquifer Test E) tyStormwater Drainage fL n. NT FROM TO MATERIAL EMPLACEME METH OD
Q
­'Experimental Technology ©Subsidence Control rL n,
EGeahennal(Closed Loop) E)Tracer 2O DRILLING LOG MIRcfi Xddldohat ihCete VAeceW
�Geolhermal(Hearin /Conlin Return Other ex lain under q21 Remarks Ta°Nt To DPseaImDN ,ewr nwn .et9rvsA Haze,<m.
b a Z n.
i SO i
":ate{Yell(s)Completed:J"JZ-Z J We111DX z R
'a.'{'ell Localion: J ido rL N
11,L t� ��� �(•L✓I/ 1✓t l V r/�p It/�D ft. n.
O..n,r Nam, Facility IDN(ifapplicable) rL n.
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1:al�nAld&ee/ss,Cio,and zip — Y 7 a-2r 2 rL ft - I
Twtl I&runcation No (PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/rnhutes/seconds or decimal degrees:
-ell ri'H one laolo g issulGcientl
35.g�388l� _ � 2ZCerification:
N )S•0_l7 3acoy W
a - - iz- z /
=fatal the well(s)�X Permanent or ©Temporary. 6igrutufe of Certified Well Contra for Date
By signing this/o.m.I hoeby ce,,Vy drat fhe,vell(s)nee pvne)coaso cled in accordance>this a repair to an existingwell: Yes or ©% No p lSANCAC 02le 0l0U ar I5A NCAC 02C OIDO IVrII Con.tlruction Standards and fhala
arcpoir,filloul Armnnuvell coruuucrion inJorrnalion n co
and ,plain IN< arure of the ropy of this record hasbnn provided to the ref/mmo.
.- under fl2)rerrrrzrl,.rea(on or nn the hock a/this/orm.
23.Site diagram or additional well details:
m'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
nlslmcljon.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Iled
�y 5 SUDMITT I INSTRI IMONS
'-Total well depth below land surface: fS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
- mrmple,Ieu,lotalld<prh,ild f<..wFe,nnrplo-I@2oo 7rrd2®loo')
construction to the following:
1,Static water level below Imp of casing: 0 (ft.) Division of Water Resources,Informelion Processing Unit,
-arc.level is above m,ing,um"�"
1617 Mail Service Center,Raleigh,INC 27699-1617
I.Unrehole diameter: 6 (in.)
24b.For Infection Wens: In addition to sending the form ID the address in 24a
1.'.1ell rnnstruction method:_ �2z,-�-f...� y above, also submit one copy of this form within 30 days of completion of well
a......oa..,cable,direct push.de construction to the following:
")3 WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground IDfection Control Program,
3 /� 1636 Mall Service Center,Raleigh,NC 27699-1636
".Yield(gpseU 0 Method of lest: Blow 24c. For Water Supply&Injection wells: In addition to sending the form to
HTH 1 lb. the addresses) above, also submit one copy of this farm within 30 days of
Disinfection type: Amount: completion of w,11 construction to fire county health department of the county
where constructed. -
North Carolina Deparel of Environmental Quality-Division Of Water Resources
Rn'ised 2-224016