GW1-2021-02304_Well Construction - GW1_20210722

?KNELL CONSTRUCTION RECORD (GW-1) .. For Internal Use Only: '
_."Veil Contractor Information: . .
Grant Mason
'VellContractorName - FROM TO DESCRIPTION I
4254A O tt- S n• 6 %®
idC\Nell-Contractor Certification Number /• 1-
IL .Z G.tL L'� /J ^'1
��nn�� pOVITl'ER�:GASINJO'..,fo1•mSilflke3ed-.wells.C)R'.I;INEIf`lilt"""Itc(iBte- - _
i�•D•V V. Poole Well & Pump CO. FROM TO DIAMETER 'THICKNESS MATERIAL
�.ompanyName + ft. S n. 6 In. .188 galv.
/_ /� �7 2S� 16'i';INNER.CASING:OR:xIfB1NG ' therriiiil.claied=lbti"
::.@i'ell Construction Pei-nlit#: '•' w^V /9>/J zoP-a FROM I TO DIAMETER I IHICKNESS MATERIAL
'.iv all applicable sell construction permits(i.e.U1C.County.State,Variance,etc.) fL ft. In.
i
,"Veil Use(check well use): ft fl. In.
water Supply Well: n0i SCREEN.,..
FROM TO •DIAMETER SLOTS ZE THICKNESS MATERIAL
al/Pbli
'Agricultural rIMunicipuc n, fL in.
jGeothemial(Heating/Cooling Supply) Residential Water Supply(single) n, fL In.
,E Industrial/Commercial [311esidential Water Supply(shared)
48i GROUT
Irrl ation FROM TO Hon-Water Supply Well: MATERIAL ( EMPLACEh1ENT METHOD k AMOUNT
V fL 2� IL
hMonitoring Recovery v fL
ft.
Injection Well:
_f Aquifer Recharge []Groundwater Remediation fL tL
?i-Aquifer Storage and Recovery [D^'�,Salini Barrier FROM /GRAVEL PACK iLa'"Ile'able
LI h FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage fL ft.
.Experimental Technology Subsidence Control fL ft.
__ 9Geothennal(Closed Loop) [DTracer 20PiDR1LLINGLOG attach iiddltloiialShEet9'1[slecessa:','
FROM TO DESCRIPTION color,hatidness,solVrock type,Smin sin etc._pGeothermal(Heating/Cooling Return Other ex lain under H21 Remarks
fL z ft. SG�
Date Well(s)Completed: �- '�-2 � Well ID# Z fL 3 ft.
z:.Well Location: )? tL 365
_PUjenZV, fL ft.
-=cility/0:ner Name ^�Facility IDN(if applicable) ft. ft. A
S31L S t/k4ro fL ft.
h•;sical Address,City,and Zip fL ft. �(r,^•3� e,{� l•On
tJl�CA_
mIty Parcel Identification No.(PIN) Used hardened steel drive shoe
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
,yell field,one lat/long is sufficient) 22.Certification:
35. R60113 N -79.72�79 o W J
a(are)the wells) X Permanent or DTemporary Signature of Certified Well Contra for Date
By signing this form,I hereby certy�that the uvell(s)was(were)constructed in accordance
s this a repair to an existing well: []Yes or [@No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
1 flits is a repair,fill out known Nell construction itJornation and explain the nature of the copy of dolt record has been provided to the Ive!!owner.
,pair under#21 renrarkr section or on the hack of this form.
23.Site diagram or additional well details:
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
ilstlitc)�on,only I G`.IV-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
rilled:
P ?OS SUBMITTAL INSTRUCTIONS
's olsl well depth below land surface: J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
-ter nurltiple mells list all depths tf diJJerennt(era iple-3@200'and 1@100')
construction to the following:
iI.Static water level below top of casing: 2_0 (ft.) Division of Water Resources,IDfortnalion Processing Unit,
rater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
3.Borehole diameter. 6 (in.) 24b.For Injection Wells: In addition to sending the form to(he address in 24a
2.Well construction method: v`� above, also submit one copy of this form within 30 clays of completion of well
_e.auger,rotary,cable,direct push,etc.) construction to the following:
i
1P.WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,RRleigb,NC 27699-1636
a.Yield(gplu) Method of test: Blow 24c.For Water Supply&Injection Wells: 'In addition to sending the form to
Ib. the address(eS) above, also submit one cppy of this.form within 30 days of
.;iU.Djsjnfectj0n type: TH Amount: completion of well construction to the couny health department of the county
where constructed.
;nav�t-I •.•North Carolina Department of Environmental Quality-Division of Waler Resources Revised 2.22-2016