GW1-2021-07338_Well Construction - GW1_20211006

'YELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: t
dell Contractor Information:
rr I 7(19
•
:*
".:14t.WATE :2AN
"`ell Contractor Name FROM TO DESCRIPTION l'.
0• 20 rL n k,
ft. fL
Nell-Contractor Certification Number �" des,��O
�
d.1N. Poole Well & Purn Co. ���� 15r,OUTE1{:CA51N(:',foEMditlEa4edwe1lii23R IMER`Zltk 1lctible
r• \O A Cj FROM F(V
O DIAMETER THICKNESS MATERIAL
+mpany Name J
+ fL ft 6 +n• 188 gal,
q� 16'INNER:CASIlVG;ORTUB1NG: thermiilcloscd=lfio
+Fell Construction Perntit N: �"" v"� ��O(�/ FROM To�TDIAMETER1rr all applicable,veil construction permits(i.e.UIC.Counrv,State,Variance,etc.) s fL i In. s_/14'ell Use(check well use): fL ln. ��LL++.
rater Supply Well: 13:SGREEN.
FROM TO DIAMETER SLOT SIZE •THICKNESS MATERIAL
Aericultural Municipal/Public lytj/ «, /,p ft. U 4 in. 40Z
'Geothermal(Healing/Cooling Supply) [i Residential Water Supply(single) 7 7 � �D v
- « fL in
induslnaliConnnercial Residential Water Supply(shared)
A GAO.iTT:;
Vlrrigation FRONS TO NSATEAIAL EMPLACEMENTMETHOD&AASOUNT
?on-Water Supply Well: v fL ? ft. I / 1
=Monitoring Recovery fL (iV Ct.
lt,,leclion Well:
F'A uifer Recharge fL N
—: q g Groundwater Remediation
;:Aquifer Storage and Recovery Salini Barrier 19:';SANDLGRAVEL:PAC&it:a"Ilcable
ty FROM TO ASATEAIAL EMPLACEMENT METHOD
_;,Aquifer TestStomnvaterDrainage fL ft.
it_xperimental Technology Subsidence Control ft. ft.
(IGeothennal(Closed Loop) OTracer 20;DRIL1INGLOG`atfsclieddlHonalBh'ietftiLnecesa''
_'Geothermal(Heating/Cooling Return) Outer(explain under#21 Remarks FROM To DESCRIPTION(color h solVrock rain size ea.
gale Well(s)Completed: Z? Z� Well ID# �j'Z fL b ft.
i
%:.Well Location: fL ft.
ility/O:vncr Name v Facility IDN(if applicable) f6 ft.
cf ft. ft.
r,sical Address,Citl.and Zip �r� ft. (L
Wake !�Q�/27/'/ =2i R)ivIATlttS t `I
Parcel Identification No.(PI N) Used hardened steel drive shoe.
Lafitude and longitude iu degrees/minutes/seconds or decimal degrees:
ell field,,one Ia-(/7long is sufficient) 22.Certification:
S(are)(he vvell(s)ox Permanent or DTemporary Signature of Certified Well Contraltor Date
0y signing this form,I hereby cert(fy that the tvell(s)ivas(were)constructed in accordance
s(his a repair to an existing well: n Yes or E]No ,vith ISA NCAC 01C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a
•+iir is a repair,fill nut known well construction igforn,ation and explain the nature of the copy of this record has been provided to the well m0ner.
:pair under#21 renrar.lr section or on the bock of this form.
23.Site diagram or additional well derails:
n 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
suuclion.only I GW-I is needed. hidicale TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Tilled:
y SUBMITTALINSTRUCTIONS
Total rvell depth below land surface:_ 20 (fr•) 24a. For All Wells: Submit this form within 30 da
1;mndtiple,,ells list all depths if d§erent(example.3@100'and 1@100') y5 of completion Of well
construction to the following:
.Static water level below top of casing: i
eater lcve!is above casing,rue"+" (ft.) Division of Water Resources,InlotTnetion Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
(. 6
Borehole diameter: (in.)
r 24b.For Injection Wells: In addition to se ding the form to the address in 24a
?.>Veil construction method: LI—C r ('� i y�- 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:
zR�1'ATER SUPPLY VVRLLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Yield($Put) __ Method of lest: Blow 24c.For Water Supply&Iniection Wells:! in addition to sending the form to
- HTH the address(eS) above, also submit one copy of this form within 30 days of s Disinfection type: Amount: 1 Ib' completion of well construction to the county health department of the county
where constructed.
r . .
.�,t,"i North Carolina Department of Environmental Quality-Division of Water Resources £
Revised 2.22.2016