GW1-2021-00337_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or mWuple wells
I.Well Contractor Information:
Ronnie Stencil 14.WATER ZONES
FROM TO DESf7RD'f1ON
Well Contractor Name 0 0` 6 «
2283-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for mWR csad wells OR LINER(if. able
FROM TO DIAMETER THICKNESS I MATERIAL
Grady Poole Well & Pump Co Inc 0 ft f D. 6 is I C,
Company Name 16.INNER CASING OR TUBIT7G eut6ermal closest-too
file no. 324482 FROM TD DIAh1LTER TDICKNTSs MATERIAL.
2.Well Construction Permit#: D. « I he.
Lm all applicable well permia fee_Canary,State. Va.rce,In/ecn.w arc/
It fL is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom To I DIAMETER I SWT s1ZE TIfICKNEs5 MArMt4l,
« « a
CAgnculmral OMunicipal/Public
❑Geahcrmal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft ia.
❑industriallCommercial ❑Residential Water Supply(shared) I&GROUT
PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Iftnininfifirt 0 fL 20 ft Bentonite Gravity
Non-Water Supply Well:
« R
OMonitoring []Recovery
Injection Wen: ft «
OAquifer Recharge ❑Groundwater Remediahon 19.SAND/GRAVEL PACK tf• Iksble
[-]Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATHRUL EsmucrnlFrT ntErnoD
R &
❑Aquifer Test ❑Stomwater Drainage ft «
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG snseh diitiemil eheeft Hnews
❑Geothermal(Closed Loop) ❑Tracer PROM TO DTSCRIPTION mlor harila. ,dVnsY r6a chu,etc
❑Geothemlal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft z ft Topsoil
1/13/2021 2 ft. " v
4.Date Well(s)Completed: Well[D# ft ,* ft /,L ✓OG IC
5a.Well Location: ft. f.
Peter Gitto ft f.
Facility/Owner Name Facility IDr{(if applicable)
D. ft.
396 Dick Baker Rd Louisburg, NC « «
Physical Address,City,and Zip 21.REMARKS
Franklin
Counry Parml Idi naficaaon No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(tfweilfield,one lavlong is sufficient) !�Jf t �/
N W 119" Llz 011131202.1
Soruture of Certified Well Contractor Date
6.Is(arc)the well(s): IDPermanent or ❑Temporary Ry signing this/.inn, I hereby ccrt6 that the well(.)was(were)c.axoncred m.....dame
with 15A NCAC 02C.0100 ar 15A NCAC 02C 0200 Well Comnucuan Standard,and that a
7.Is this a repair to an existing well: OYes or FINo copy of this record has been provided to the well owner.
1f this is a repatr,fill oat known well conatuc0an information and explain the ranee of the
repair under k21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or Well
8.Number of wells constructed: One construction details. You may also attach additional pages if necessary.
For mWuple injection or now-wanersupply wells ONLY with thr Samna rorwtraeaoa,you can mbnmt one form. SUBMITTAL INSTUCTIONS
))
9.Total well depth below land surface: Ct�Q (ft.) 24a. For An Wells: Submit this form within 30 days of completion of well
Fmmvluple welhirri.11dewhs fdigerent(esample-3@200'.nJ2@100') C i uclI'Gj�4}bp Itv g'.
Z C7 Division of W ater Resources,Information Processing Unit,
In.Static wafer level below top of casing: SfL),, n g
/Jwarer lave!is nbove casing,use" i,i�� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Air Rotary construction to the following.
it a auger,mtary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY QWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: BLOW 24c.For Water Supply&Injection Wells:
Also submit one copy of this form Within 30 days of completion of
13b.Disinfection type: HTH Amount: 1 Lb. well construction to the county health department of the county where
constructed.
Form Go''-1 North Carolina DeparvnentofF,avironment and Natural Resources-DIVISLon ofWhter Resources Revised Auguv 2013