GW1-2021-02305_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-I) F®rternet Use Only:
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....Well Contractor Information: I
grant Mason h 14;i.W.ATEIk,Z.0NE5_ - k
FROM TO ."DESCRIPTION I.
e11 Contractor Name
H.
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N Well'Contractor Certification Number 15 O.UTER::CAS1NGi fdEIi1h1�' .Well!�,CIR`LINER:tf i IIc66iA.. .':.':....
?'#.IN. Poole Well & Pump CO. FROM TO DIAMETER THICKNESS MATERIAL
ft. 1 6 In. 188 gals.
bmpany NameC�¢
/ , `�� �*I�,,,,�J Q L � a Z d .:16�INNEII.CASIf.( OR�.2:[1H .G, .,.,.:therrital cl'oBed.Ibo'
Well Construction Permit 1,:6- ^ l v Z. FROM TO DIAMETER THICKNESS MATERIAL
ist all applicable well construction permits(i.e.UIC,Count•.State,Variance,etc.) fL n In.
Well Use(check well use): ft. ft. In.
19i SGR$EN `I
'rVater Supply Well: ,..-.• . I —
FROM TO DIAMETER SLOT S ZE THICKNESS bATERIAL
SAericultural [)Municipal/Public tt, IL In•
JGeothetmal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL In.
flndustrial/Commercial 011esi&rilial Water Supply(shared)
Irrigation FROM TO MATERIAL I ENkACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0
fL
Monitoring ORecovery ft. ft.
i Injection Well: I
fL ft. i
tAquifer Recharge Groundwater Remediation
_ 19:i5ANDlGRAYBLPACK':1f:a 'llcable =
+ts.quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
tAquifer Test [3Stormwater Drainage rL ft.
)Experimental Technology Subsidence Control fL n.
hGeothennal(Closed Loop) [37fracer oi;DAILLTNG'I OG attaeHaddlHoiibh 8ee16ff,Ntcessa
^'lGeothenmal(Heatin Coolin Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hvJdness solprock rain size etc.
_ ft. ft. 1 /f
Date Weil(s)Completed:3 Well ID# fL ft.
Well Location: t `
'�L
chity/0,vner Name Facility ID#(if applicable) rL R.
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-,sical Address,City.and Zip a _r ; ()
tf��/i•, / ,i3l:REMARKS;a . .. �;;,, .:- t:t.., ..4. :;r ,:.r. .a" to e
Parcel Identification No.(PIN) Used hardened steel drive shoe.
^.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
cell field,one lat/long is sufficient) 22.Certification:
3`5.332`429 N -19.1-4 7I 1-W 3,2 Z
tare}the wetl(s) Pet moment or OTemporary Signature of Ccttifted Well Contra for Date
By signing this form,i hereby cerlio that the wells)was(were)constructed in accordance
?.5 this a repair-to an existing well: [Dyes or E}No ivith ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Nell Construction Standards and that a
F rhiF is a repair,fill our known well construction information and explain rile nature of the copy of this record has been provided to the well owner.
pair wider#21 remarks section or on the hack of this form. 23.Site diagram or additional well details:
1.Tor 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
r nsinicpon.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
fled: 1 SUBMITTAL INSTRUCTIONS
Total well depth below laud surface: 3F- (ft.} 24a. For All Wells: Submit this form within 30 days of completion of well
�r mulliple.cells list all depths if d fferehl(example-3@200'and 2@100') construction to the following:
?`.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
meter heret is above casing we"+" 1617 Mail Service Center,Raleigh,NC 27649-1617
.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
L t>ti'eH construction method: above,also submit one copy of this form within 30,days of completion of well
/� Y
..e.auger,rotary,cable,direct push,etc.) construction to the following: i
Division of Water Resources,Underground Injection Control Program,
0I1 WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Ralelgh,NC 27649-I636
30-1,1,Yield{gpnr) Method of test: BIOW 24c.For Water Supply&Injection Wells: In addition to sending the fonn to
the address(e5) above, also submit one cppy of this.form within 30 days of
Disinfection type: HTH Amount: Ib" completion of well construction to the couny health department of the county
-- where constructed.
c::171 G'X.I .f North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2.22-201 G