GW1-2021-02246_Well Construction - GW1_20210722

V.NELL CONSTRUCTION RECORD (GW-I), ,. For Internal Use Only.
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' Well Contractor Information:
Grant Mason
19dWATE 'ZON771,
/ell Contractor Name FROM TO I DESCRIPTION I.
4254A X fl. 7 ft' <U ltl
ft. ft.
Well'Contractor Certification Number
p ',15tt0.WT,ERGA5iNG;fdi•rridlNfkaseil:welli-:Cf.RliINER ifi""Iic(itil� -
i'l.�N. Poole WBII 8t PUl11p CO. FROM TO DIAMETER iIItCKNESS I<fATERIAL
+ IL
- It. 6 in 188 I galy
3 l I 16 dNNER.CASING OR,x UBING therFiiiJ elbsed:lbu
? Well Construction Permit N: / FROM TO DIAMETER THICKNESS MATERIAL
�.ist all applicable well construction permits(i.e.UIC.Count),.State.Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. In.
?relater Supply Well: 11ESCREEN: ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural OMunicipal/Public f1. ff. In.
_[iGeothermal(Heating)Cooling Supply) XDResidential Water Supply(single) ft. ft. in.
Ondustrial/Commercial [D]Residerilial Water Supply(shared) 1;18t
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
??on-Water Supply Well; It 7 U It. /
JMoniloring Recovery fL ft.
injection Well: fL fL
_!Aquifer Recharge Groundwater Remediation
i5ANDLORAVEL PACIf
FAquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENTMETHOD
_)Aquifer Test E)Stormwater Drainage Ill. ft.
+Experimental Technology Subsidence Control ft. ft.
bGeothennal(Closed Loop) [)Tracer ::20:;DRILLING100;iitticliiiildltiontilkeet�ifilecea':
FROM TO DESCRIPTION(color,hardness,sollfrock a rain slu ate'
_ •3
Geothermal(Heating/Cooling Return Other(explain under 921 Remarks ft. rC '`°
/ C c51
-
✓ate AVell(s)Completed:.- !S 2� Well ID# z ft. ft. C. A
Well Location: IL ` It. �t.r,r��. 'h •� ��\L j1l�J I�(1 'J ( 1 tL n. erg\(��
--.614h40wner Name Facility IDN(if applicable) _ f6 ft. P4'tO'{�
IS O -a-Ine rc, Id F-&,a l�/,�l/ �t/t Z ft. n.
=h sical Address,City,and Zip ft. ft.
.�U Z _2ii.REMAR$S! a 1
::nrtiy Parcel identification No.(PIN)
Used hardened steel drive shoe.
"i7.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field,one lot/long is sufficient)
N _'7 ,S5_z9�y/�
q w 22.Certification:
S(are)the well(s)EIPer•manent or Temporary Signature of Certified Well Contra for Date
By signing this form,I hereby Geri fy that the ivell(s)was(were)constructed in accordance
Ts(his a repair to an existing well: QYes or No nvillt 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
r rhis is a repair,fill air(known well corurruction information and explain file nature of the copy of this record has been provided to the well owner.
:emir under N21 remarks section or on the back of finis form.
23.Site diagram or additional well details:
For 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
tsttltclion.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Grilled: II � SUBMITTAL INSTRUCTIONS
Total is ell depth below land surface: I L'S (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
.11 anthiple wells list all depths I(dii ferelt(exantple-3@2000'and 2@100') construction to the following: j
!.Static water level below top of casing: (J (ft.) Division of Water Resources,Information Processing Unit,
,rater level 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
fC Y above;also submit one copy of this form iwithin 30 days of completion of well
:.'-fell construction method: t� construction to the following:
.e.auger,rotary,cable,direct push,'etc.)
Division of Water Resources,Underground Injection Control Program,
OR.WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
�.1.Yield(gpm) C Method of test: BIOW 24c.For Water Supply&Inieclion Wells:I In addition to sending the form to
HTH
1 lb. the address(el) above, also submit one c'ppy of its.form within 30 days of
b.Disinfection type: Amount: completion of well construction to the couunty health department of the county
-- where constructed.
;ir+.G\1%-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016