GW1-2021-02241_Well Construction - GW1_20210722

1.- :Prlri�RFa�m
-f ELL CONSTRUCTION RECORD (GW:L :, For Internal Use Only: '
;Nell Contractor Information:
Grant Mason
MATERZONFS
0N
`Nell Contractor Name _ FROM i0 DESCRIPTION '-1
4254A ISO IL
ft. .fL
N',-lvell'Contractor Certification Number
15t;tO11TER CASING;friFmdltl ased wellb,
It7R';LINEIt."ICi" e
ON. Poole Well & Pump Co. FROM TO DIAMETER V THICKNESS "IlctililMATERIAL
t fL 62 7 ft. 6 In. $8 galy.
ompany Name
D� ft. dl elo i'
16 INNEk.CASII9GORTUBING`'eotharrif•
.- @3'ell Construction Pernfit H: - - FROM 70 DIAMETER inICKNEKKE 55 MATERIAL
Jv all applicable well construcrion permits(i.e.U1C.County,Stale,Variance,etc.) fL In.
;?Jell Use(cirecic well use): fL H. In.
° clot Supply Well: 11t SCREEN:,
FROM TO ^DIAMETER SLOTSIZE THICKNESS' hATERIAL
tlgricuhur l nMunicipal/Public ft. ft in.
iGeothermal(Heating/Cooling Supply) xMResidential Water Supply(single)
ft. fL fn.
Industrial/Commercial [3Reside6lial Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD d AMOUNT
i`lon-Water Supply Well: Q ft ZV ft. U1t
:Monitoring Recovery ft ft.
fsr.jeclion 1i'ell:
^f'rlquifer Recharge []Groundwater Remediation R fL
niter Storage and Recovery 19riSAND1GBAVEL'PACK Nii"`Ikable
A '
q g q' Salinity Barrier FROM TO MATERIAL EhIPLACEMENThiETHOD
_'Aquifer Test E)Stormwater Drainage rL ft.
_'0Experimental Technology Subsidence Control fL ft.
hGeothennal Closed Loop)P) Tracer 20.;f5RILLINGLOG iitfach:§ddltioiial heet$i
lfllecessd'_
FROM TO DESCRIPTION color,Mudness,soll/rah type,grainslu c1c.
_pGeothermal(Heating/Cooling Return) nOther(explain under 921 Remarks rt ft
5� J C
Date NVell(s)Completed: Well IDN fL Z ft. C /
Well Location: 'Z fL ft.
// I'Lt,4 I J
/�mCS fL n. �3 {
7;.6liiy/Owner Name Facility IDN(if applicable) ft ft, •) r 202`
10fe U4/fC f 104 `l SUn e5 c. I�� '�o !� rL ft. B oe,Sin9 unit
SEA C
'hysical Address,City,and Zip
-7SrY7 fL ft. n '
1 t:tc Parcel Identification No.(PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/mInutes/seconds or decimal degrees:
r�elll�l field,one lat/lo��nng is sufficient) Q 5111
J 22.Certification:
3Vf-OS5 d[W N .. �U 5111Z /' W
'-S(are)the well(s)E% Permanent or Temporary Signature of Certified Well Contra for Date
0p signing this form,1 hereby term that the weN(s)lvas(were)constructed in accordance
this a repair to an existing[yell: []Yes or @ No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consirticiion Standards and that a
r!hi.c 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 oivner.
.pair under 421 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
;nstntclon.only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Stilled:
�0 SUBMITTAL INSTRUCTIONS
Total well depth below land surface:nndtiple molls list all depths if differeint(example-3[t 100'and 1�il)00') (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
" U Z.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
rarer love/is above casing,use"+" 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
Well construction method: f above,also submit one copy of this form within 30 days of completion of well
construction to the following:..e.auger,rotary,cable,direct push,ercJ '
'OR WATER SUPPLY WELLS ONLY: Division O[Water Resources,Underground Injection Control Program,
Blow 1636 Mail Service Center,Raleigb,NC 27699-1636
Yield(Spin) Method of test: 24c.For.Water Supply&Injection Wells: In addition to sending the form to
HTH Ib the address(e5) above, also submit one cppyjof this form within 30 days of
__6.Disinfection type: Amount: completion of well construction to the couitty1 health department of the county
where constructed.
North Carolina Department of Environmental Quality•Division of Water Resources Revised 2-22-2016
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