GW1-2021-02237_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD (GW-1.1. .. For Internal Use Only: a
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?.Well Contractor Information: . . J (Qf�
Grant Mason 19';YVA1 R N
-�`:ell Contractor Name FROM TO I DESCRIPTION
4254A ft. o�76 n. $ /yi
ft. .n.
Nf Well-Contractor Certification Number ` &1-.0.LiTER.CASING'ftif.hiultlke3ed:we113;OR�aiINERi Its' ili:jlile L•`
N.W. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
+ n 'K3 n. 6 I" :188 gale
-ompany Name -
.j6 JNNER'.CASING 0R MWG*: theritial el'oaed ltw
Well Construction Permit ll: Q( (� FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable ivell construction permits(i.e.UIC.County,Stale,Variance,etc.) H. ri• I"
Well Use(check well use): fL ft. i°•
11.SCREEN:L
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
lAgricultural E)Municipal/Public ft. f. in.
,;Geothermal(Heating/Cooling Supply) xOResidential Water Supply(single) ft. ft. tn.
JIndustrial/Commercial DResidetitial Water Supply(shared) 1tirGROUT., ::.
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
i Non-Water Supply Well: fL U ft.
( /_ �(� G v
Monitoring ORecovery ft. ft. aC
i-Iniection Well:
ft. ft.
Recharge E)Groundwater Remediation
193AND/GRAVEL'TA :Ifti 'ilceble
(jAquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stortnwater Drainage ft. ft.
:.Experimental Technology OSubsidence Control ft. n•
�@Geothermal(Closed Loop) Tracer 0!;DRILLIItIGLOG:sttachriddiiibM11hEetrif ieFes�a
..'._]Geothermal(Heating/Cooling Return Other(explain under#21 Remarks FROM 70 DESCRIPTION eato�haranaa auivrock grain size,etc.
) rL Z ft. 70,(
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<.Date Weil(s)Completed:L—2 Z Well ID# rL / ri• 6116
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Well Location: it ft O
ft «.
y Cv d'Ir�i�e 1�i�.SEA
z6lity/0,,ner Name Facility IDH(if applicable) ft
ass 7 Zae bs ( s-k M NC a75e�
-hN sical Address,City,and Zip ft. ft. 1 rO� cg1R9
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Ili;REMARKS',f4 nvl`i"(e parcel Used hardened steel drive shoe
h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if.�ell field,one tat/long is sufficient) 22.Certification:
_3C0.^Lo.3�-RZ N `�1$• 7F1�-70 w
s(are)the vvell(s) % Permanent or Temporary Signature of Certified Well Contra for Date
By signing this form,I hereby certify that the well(s)ryas(were)constructed in accordance
[s this a repair to an existing well: nYes or E)No with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
;(this is a repair,fill air[known well construction it formation and explain the nature of the copy of this record has been provided to the well owner.
apair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:.
.:i'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
constntc on.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
Total well depth below land surface: �s M-) 24a. For All Wells: Submit this form within 30 days of completion of well
-a,nuthiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
-.•`.?.Static water level below top of casing: Za (ft Division of Water Resources,Information Processing Unit,
rr❑ater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
I.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
z
J� y( above,also submit one copy of this form within 30 days of completion of well
;Z.Weil construction method: I -✓ construction to the following:
_.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
0R WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3x.Yield(gpm) A Method of test: Blow 24c.For Water Supply&Iniection We1lsI: In addition to sending the form to
the address(es) above, also submit one copy:of this form within 30 days of
1 Ib.
b.Disinfection type: HTH Amount: completion of well construction to the county`,health department of the county
where constructed. I
i
-ctrt G NV-I North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2616
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