GW1-2021-07172_Well Construction - GW1_20211006

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'OVELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:n —7
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.Well Contractor Information: '
Grant Mason
E 14 WAVE '20N
eII Contractor Name FROM TO DESCRIPTION I
4254A U fL /Y5 ft-
- fL .tL
'C +'ell-Contractor Certification Number
I&DUTER4,CASING;fol lifdlflRaSed p'e119;CfR`LINERZItii"Ilefible
i`d.iN. Poole Well & Pump Co. FROM TO DIAMETER TIfICKNE55 MATERIAL
�ougianyNaiue + rL y n. ;DA
in. •188 galy.
�J '[,1i2;62NNER_CASING::ORZ' G..'.:`th'er'riiii1
Yell Construction Perndt N: 3o r�9 FROMTO METER THICKNESS AtATER1AL
isr all applicable%veil consu'nction permits(i.e.WC,County,State,Variance,etc.) rL ft. In. I
%Jell Use.(check well use): ft. it. In.
dater Supply Well: ay SCREEN:
-- FROM I TO DIANIETEA I SLOTS ZE I• MATERIAL
Agricultural ®I Municipal/Public
r eothermal(Healing/Cooling Supply) x Residential Water Supply(single)
ft fL in
!:Industrial/Commercial Resideritial Water Supply(shared)
;18i GROUT:;:: f:r
5irri alion FROM TO MATERIAL 1 EMPLACEMENT METHOD&Ah10UNT.
-1don•t•Vatet•Supply Well: � fL �� tt. L, Q/U l
�f-Monitoring ry fL ft.
Recove F a
o.iec(ion Well:
r aquifer Recharge []Groundwater Remediation fL fL
';Aquifer Storage and Recovery Salini Barrier 1 SANDLGRAVEL:PACIF:If ii`'!(cable
ty FROM TO I MATERIAL EMPLACEMENT METHOD
_^Aquifer TestSlormwaler Drainage fL ft.
__iiFsperimental Technology
Subsiderice Control fL ft.
IGeothennal(Closed Loop) Tracer 201DRILIiING.LOGi iitibchaddltlohat'stiEet�ilfitecessa'
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,solllmlk typeignin alu etc.
rL n• v SC'r C
Tjate Well(s)Completed:y -2/ \Yell IDN fL 0 ft.
VVell Location: / fL 0
NOMCS rL rl. C 2,1
�.cilii�/Owner Name fL ft. . V \�
Facility IDN(if uC�
� t2,( L fJ yr s bV j Alc a Sy y ft. n• sstn9
,3t0� '10n
h,sical Address,City,and Zip ft rt. Q SA
?21iREMARKS 1S
Parcel Identification No.(PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
•`°:ell field,one tat/long is sufficient)
CILIOu �� �� I 22.Certification:
N �1 w J2J .
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(are)the+rell(s) Pet'ntanenl orTemporar}' Signature of Certified WellConirator Date
Dy signing ibis form,I hereby certify that die ivell(s)ryas(were)constructed in accordance
%s(his a repair to an existing well: Q Yes or EJNo ivilh 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Yell Construction Standards and that a
::,;'I is is a repair,fill out known%yell construction ii formation and explain the nature of(lie copy of this record has been provided to the ivell owner.
„air raider N21 remarks section or of rite back of this forin.
23.Site diagram or additional well details:
or 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
m5l"Ic on.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
).Tilled:
�f SUBMITTAL INSTRUCTION
Total well depth below land surface: �CJS -(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
- nnrltiple%cells list all depths if dWerelit(example-3Q100'and 2 t(_Q100') ..
construction to the following:
'.Static water level below top of casing: 00 (ft.) Division of Water Resources,'Hater level is above casing,use"+" Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
:..'•:fell construction method: � r% above,also submit one copy of this form within 30 days of completion of well
e.auger,rotary,cable,direct push,'etc.) construction to the following:
1R.WATER SUPPLY WELLS ONLY: o e Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699.1636
Yield(BPrm)-- 7 Method of test: Blow 24c.For Water SunDiv&Infection Wells: In addition to sending the form to
_ Disinfection type: HTH Amount:
lb..' the address(eS) above, also submit one cppy of this-form within 30 days of t?. completion of well construction to the county health department of the county
where constructed. i
7 { '
North Carolina Department of Environmental Quality-Division or Water Resources
Revised 2-22-2016