GW1-2021-02333_Well Construction - GW1_20210722

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10VELL CONSTRUCTION RECORD(GW-ll. .. For internal Use Only:
Well Contractor Information:
Grant Mason 14;WATE `ZON
tell Contractor Name FROM TO I DESCRIPTION !:
4254A 6 5 fL p It.
ft. fL
i C"'eifContractor Certification Number
n/ Ift-OUTER CASING.fol�.iiibit(-Fab'ed:ri°ells):bltiLINER U:fi- Ikabli
i\J,.W Poole Well & Pump Co, FROM To DIAMETI THICKQNESS hiAT£RtAL
-i m U`. ft. 6 In. 1$U galy.
'ompany Name _
73L c/�,� 16:INNE1t.CASING OR:TUBING;'"'"'therdi
Well Construction Permit N: FROM I TO I DIAMETER THICKNESS MATERIAL
�.W all applicable,cell construction permits(i.e.U1C.County.State,Variance,etc.) fL ft. In
Well Use(check yell use):
ft. ft. In.
'.Voter Supply Well: lei SCREEN'
_ FROM TO DIAMETER SLOTS ZE THICKNESS MATERIAL
Agriculnhral C]Municipal/Public ft. ft. in.
IiGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
Industrial/Commercial QiResidetitiai Water Supply(shared) 38i GROUP
._ Irrigation FROM TO MATERIAL ! EMPLACEMXNT METHOD&AMOUNT
Mon-Water Supply Well: ft. ft. ? /< /J�
_hvlonitoring Recovery ft. ft. Y `
srJection Well: fL ft.
tAquifer Recharge Groundwater Remediation
193AND/09AVELTACK lf:is 'liceble
Aquifer Storage and Recovery [3Sahnity Barrier FROM TO MATERIAL EA(PLACEMENTMETHOD
,,-.,Aquifer Test 0Stonmwater Drainage tL ft.
._JExperimental Technology Subsidence Control
_ r
Meothennal(Closed Loop) [37fracer 30i;DIt1LLING`.L'OG:ettacli a8dliloiiat tieeliS UHeeessa
FROM I TO DESCRIPTION(color,hardness,solVnxk type,Itmin size etc.
_;Geothermal(Heating/Cooling Return) FlOther(explain under 421 Remarks) ft. Z ft r
i
state Well(s)Completed: -R 2 (Well IDN ft. ft. /GZ4
Well Location. ft.
(L
-Rcihrv/tttvner Name Facility iD#(if applicable) IL ft. `✓ +
7 t f t. I'L
2 t ��t.�_`I ems !` L�I ref tc1 J� ,,,,q �
sical Address,Cite,and Zip ft. ft. JD t,%A
�^i��Ut f rC zi REi1lAiixs:! .'• ; :.t . ..¢ _,. __I- d ,-.;�n
antae Parcel Identification No.(PIN)
Used hardened)steel drive shoe 1�'i40«l �NR' s
.La titude and longitude in degrees/minutes/seconds or decimal degrees:
�jelll field,one Ial/long is sufficient) /� 22.Certification: /
IS(are)(lie vvell(s) Permanent or Temporary SignatureotCetvifiedlVellCon Date
x
Oy signing this form,1 hereby cerly�that the well(s)was(were)constructed in accordance
is(his a repair to an existing well: [DYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.02,60 Well Constriction Standards and that a
i his is a repair,fill via known well constriction htforntation and explain the nature of the copy o(iltis record has been provided to the well owner.
epnh under#21 remarks section or an the back of this fornn.
23.Site diagram or additional well details:
2 o-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
onstnic on,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
`;`filled SUDWTITTAL INSTRUCTIONS
To(al well depth below land surface: 30 S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
aunt/tie wells lit/all depths if d ereiit(example-3@200'and 2@100') construction to the following:
`•Static water level below tap of casing: 2o (ft.) Division of Water Resources,Information:Processing Unit,
.i:rater level is above casing,,use"+" 1617 Mail Service Center,Ralelgh,NC 27699.1617
V i
L Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to lite address in 24a
above,also submit one copy of this form within 30 days of completion of well
Well construction method: construction to the following: l
..e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergro`Iund Injection Control Program,
?R SKATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rileigh,NC 27699.1636
Yield(gin) 1 Method of test: Blow 24c.For Water Supply&Injection Well : In addition to sending the form to
Tt�3 the'address(es) above, also submit one egpy of this form within 30 days of
36.Disinfection type: r Amount: lb' completion of well construction to the county'health department of the county
where constructed.
4
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-20I6