GW1-2021-02240_Well Construction - GW1_20210722

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1?VELL CONSTRUCTION RECORD (GW-1) .. For Internal Use Only:
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"Veil Contractor information:
Grant Mason i9 15ATE iZON
,'ell Contractor Name FROM TO I DESCRIPTIONh.
4254A I ZU It. 2 n, LD S0rx
fL ' . 41. j
=C Well•Conuactor Certification Number IStOUTER:GASING.;tormultli.W-ed.nells.b1V11NER Uk""Iletilile
I1•I.W Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
+1 fL n. g 1- 188 gals.
ompany Name
2 0 .l6.:1NNElt.CAS G:OR7'I,BING ebthecitialclbsed:llib'
:Fell Construction Permit#: ._./� O FROM TO DIAMETER THICKNESS MATERIAL
�.isr all applicable well construction permits(i.e.UIC,Comity,Slate,Variance,etc.) rL ft. In.
+,dell Use(check well use): fL rt. In.
Hater Supply Well: FR•n1REE TO DIAMETER SLOTSIZE I THICKNESS' MATERIAL
.Agricultural nMunicipal/Public N, fL In.
.Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) R fL in.
InduslriallCommercial Residential Water Supply(shared) J86 GROW— ,
_a Irii all0lt FROM I TO MATERIAL EMPLACEMENT METHOD&AA107JNT
Non-Water Supply Well: fL Zv ft.
Nlonitoring Recovery fL ft. t L N�
.oiection Well:
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Aquifer Recharge Groundwater Remediation
10 SAND/GRAVED PACK ita""Ilcable .:
iAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test DStormwater Drainage fL ft.
ilExperimental Technology Subsidence Control fL ft.
)Geothermal(Closed Loop) E)Tracer 20';DRILL1NGabG:iittacliAddltlbnaL$beet9iif,ttecelNii
;Geothermal(Heating/Cooling Return Other(ex lain under 921 Remarks FROM To DESCRIPTION(color,hardness aolVroek a ralnstu ate.
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Date Well(s)Completed: -a Z r Well ID# fL fL G
%;.?Nell Location: fL ft. rli'?i,;,�
-TC G• Home-.) fL 1I, � 2021
'=cility/O,vnerName Facility lDN(if applicable) fL ft.
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13�9 c he,me,on Dr wal4 fe3a ti n ft. ft.c a �� .: �•on
°hvsical Address,City,and Zip rL ft. �6•i:it1;' `%Nr^4
i21 REMAR$S :.
irf G nyr Used hardened steel drive shoe.
a' Parcel Identification No.(PIN)
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,ell field,one lat/long is sufficient)
3� • 0� L-� — -•7/_ 22.Certification:
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=(are)the well(s) x Permanent or DTemporary Signature of Certified Well Contra for Date
By signing this form,I hereby certy�that the well(s)it-as(ivere)constructed in accordance
i;this a repair to an existing well: E3Yes or EJNo ivith ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
i lhi.i i.s a repair,fill on known ivell construction information and explain die nature of the copy of this record has been provided to the ivell owner.
,hair under#21 remarks section or on the hack of this form.
23.Site diagram or additional ii•ell 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
Dilstl'tic(jon.on]),I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
i filled: I SUBMITTAL INSTRUCTIONS
.Total well depth below laud surface: I�S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of wet l
.�r mutriple hells list all depths if different(example.3@200'and 2@i00') construction to the following:
'0.Static water level below top of casing: ao (ft.) Division of Water Resources,14.nnation Processing Unit,
„arer level is above casing,use'• " 1617 Mail Service Center,Raleigb,NC 27699-1617
?.Borehole diameter: 6 (in.) 24b.For Iniection Wells: in addition to sending the forth to the address in 24a
:yell construction method:
above, also submit one copy of this formllwithin 30 days'of completion of well
:. �r Y I i
'i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
OP WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
35:.Yield(gpni) 20 Method of test: Blow 24c.For Water Supply&Iniection Welts:' In addition to sending the form to
1 Ib• the address(es) above, also submit one cppy of this.form within 30 days of
:b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed. f
�`•�` I i North Carolina Department of Environmental Quality•Division of Water Resources Revised 2.22.201 G
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