GW1-2021-07455_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD GW-1.). � For Internal Use Only:
':..well Contractor Information:
Grant Mason �7 _rik19cWA2E.70N t
"'ell Contractor Name - - OM TO DESCRIPTION ! i
4254A 0 6 �n9\ 30 fL 13 ft. 34 ..
r� �e�S tL fL
<.Well'Contractor Certification Number C\r' J��Qn
J �(� CJe 15r,,OUTERGASI]!IG.;ftiF.ir161fled welli tOR IiINER- "ll@fible
' UN. Poole Well & Pump Co. �� � FROM TO DIAMETER ITIIICKNESS MATERIAL
<<`` �N + rL H. 6 In• .188 galy.
ontpany Name \
/�/, 16:INNER:CA INGOR:TUB1NG$"' th'ei'iilal el6&ed?loo"
'.Well Construction Permit N:IzW C) �7Gl3-0020 FROM 70 DIAhfEIER I THICKNESS hATERIAL
is/a//applicable well construction permits(i.e.UIC.County,State,Variance,etc.) fL ft. In.
Well Use(check well use): fL ft. in. '
rater Supply Well: �`M SCREEN:
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
SAericuhural IDMunicipal/Public H. tL In.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) --- fL In.
«.Industrial/Commercial DResidetitial Water Supply(shared)
,481 GROUT!::';
711rTip,ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water-Supply Well: o fL v ft. O L / y r
__Monitoring 13Recovery ft
ft.
rjeclion Well:
fL fL
tAquifer Recharge Groundwater Remediation
;Aquifer Storage and Recovery Salini Barrier 19:$AND/GRAVEL PACK iL•a'"Ilcabla ;r,
h' er MATERIAL EMPLACEMENT METHOD
_^Aquifer Test FROM 70 Stormwater Drainage fL ft.
_ Experimental Technology Subsidence Control fL ft.
)Geothermal(Closed Loop) [)Tracer 20IDRILLINGLUG!ells¢h.iiddliloiWleNeeta}IG>Vects$a `{
3Geothermal(Heating/Cooling Return Other(explain under ll2l Remarks FROM TO DESCRIPTION(color ha dness,solVmk min slue etc.
O f6 ft. SO jC
Date Well(s)Completed:�i[�{_2/ Well ID# 2 fL ft. ry
Well Location: fL Stt. -y�^n`j-t
3s c..\ o, capnc/! ft. ft.
'-cility/Owner Name Facility IDN(ifapplicable) fL ft.
SZ� 5 Pe n c e Fc.,rlh A2e4 tt.y 5er I na S 1-" n.
'hysical Address,City,and Zip a 7Sg0 ft. ft.
Wct� 21 RE$IARKS
C` Parcel Identification No.(PIN) Used hardened steel drive shoe.
'n.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field,one hat/long is sufficient) 22.Certification:
W
=(are)the well(s)oX Permanent or Temporary Signature of Certified Well Contra for Date
By signing this form,1 hereby cert jo than the rvelf(s)ivas(were)constnrcted in accordance
s this a repair to an existing well: E)Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
-0hie is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
,;Pair under#21 remarks section or on the back of this form.
23.Site diagram or additional well detailsi
^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
-,nsiluc on.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
:Billed: I
/� SUBMITTAL INSTRUCTIONS
Total well depth below land surface:__ fj --(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
nudtiple veils list all depths if dierefit(example-3@200'and 1 a 100')
construction to the following:
s( Static water level below top of casing: Z G (ft.) Division of Water esources I
.f.rater level is above casing,use"+" R , rrforiDation Processing Unit,
6
1617 Mail Service Center,Raleigh,NC 27699-1617
I.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.!Veil construction method: k_,- y above,also submit one copy of this forth within 30 days of completion of well
e.auger,rotary,cable,direct push,etc.) construction to the following:
'11H WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Infection Control Program,
1636 Mail Service Center,Ralelgh,NC 27699.1636
.geld( In Blow
gP ) d Method of test: 24c.For Water SuoDly&Infection Wells: In addition to sending the form to
1 Ib. the address(eS) above, also submit one copy, of this form within 30 days of
3b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
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North Carolina Department of Envirotunental Quality-Division of Water Resources Revised 2.22-20I6
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