GW1-2021-02258_Well Construction - GW1_20210722

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-WELL CONSTRUCTION RECORD (GW-1.1 For Internal Use Only:
:.'!'dell Contractor Information:
Grant Mason
_ 14:'WATE 'Z0N
"ell Contractor Name FROM TO DESCRIPTION 1.
-
4254A d fL 5 ft. llJ 0/i
fL . .ft.
dCWellConuactor Certification Number I&OUTERCASING; 6niiilfl�aiedwells OR`LINEREIf>i"IlcYlile
NON. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
+ ft. G R. 6 In. 188 galy.
'bmpany Name -
I� A .:16:INNER.CASING:6R:TUBING' thefibiileladedabo
W `ell Construction Permit#: aO— (J U]SY /') FROM I TO DIAMETER I THICKNESS MATERIAL
'.ist all applicable well construction permits(i.e.UIC.Coumo%Stale,Variance,etc.) fL ft. in.
Well Use(check well use): f6 ft. In.
dater Supply VVel1: 19:SCREEN:
FROM TO DIAMETER SLOT SIZE THICKNESS hf ERIAL
_L'Aericultural OMunicipal/Public % R. fL in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) f ft. ft. in.
9Industrial/Commercial Residential Water Supply(shared) 18t GROUT;. .:,.
Irrigation FROM I TO TATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL 20 ft.
_-Monitoring Recovery fL ft.
injection Well:
fL fL
'Aquifer Recharge Groundwater Remediation
19:`SAND/GRAVER'PACK'lf,ii0 livable
,.Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage fL / ft. A Lv�
^'Experimental Technology Subsidence Control fL G ft.
;._JGeothenml(Closed Loop) [DTracer ;20t;DRILLINGLOG'INWch'iiddltfonal.sheet
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardnes s,soll/ivek type,gnaln slu etc.
rL 2 fL p 5d�
:.Date 13`ell(s)Completed: �� !p
—Z r Well ID# ft. fL � %
%;.'Nell Location:
lny/ her Name Facility ID#(if applicable) fL ft. ,`` Ut},�
13 ls3 W v Icy sPr4 A le'. rut��Itfe;l 111C n. U nr JL cur
'Il sical Address,City,and Zip 7 �— f6 ft.
21'REMARKS S: I
Parcel Identification No.(PIN) Used hardened steel drive shoe.
i3.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ii well field,one lat/long is sufficient) l 22.Certification:
�-T SQt(�S CQ_N `����"L`�.� 11 W
's(are)the well(s)oX Permanent or Temporary Signature of Certified Well Contra for Date
_ By signing this form,I hereby cert�that the ivell(s)ryas(were)constructed in accordance
is this a repair to an existing well: nYes or EJNo ivilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
rlti.c is a repair,fi!(aw known well construction it formation and explain the nature of the copy of this record has been provided to the ivell owner.
epnir under#21 remarks section or oil the back of this form.
23.Site diagram or additional well details:
-vot Geoprobe/DPT or Closed-Loop Geothermal Wails having the same You may use the back of this page to provide additional well site details or well
,nsuucl�on,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
Iri I led: // SUBMITTAL INSTRUCTIONS
Total well depth below land surface: - IV� A) 24a. For All Wells: Submit this form within 30 days of completion of well
.nr inuhiple wells list all depths if dii fermi(example-3@200'and 1@100') construction to the following:
I.Static water level below top of casing: 7i0 (ft.) Division of Water Resources,Information Processing Unit,
wale,/cve/is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699.1617
i. 6
Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method:
above,also submit one copy of this formiwithin 30 days of completion of well
cons
..e.auger,rotary,cable,direct push,etc.) truction to the following:
1
Division of Water Resources,Underground Injection Control Program,
O)!t WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
/) Blow
a.Yield(gpm) V Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
hlTl-I the address(eS) above, also submit one cppy of this forth within 30 days of
'b.Disinfection type: -Amount: 1 lb.- completion of well construction to the county health department of the county
h were constructed.
t - i
G'`1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016