GW1-2021-00811_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD Far lotemal use ONLY
This form can be used for single or multiple wells
1.Well Contractor information:
Ronnie Stencil 14.WATER ZONES
FROM TO DiSCRDRION
Well Contractor Name 0 1
4 o C) It
2283-A n. I fL
NC Weil Conrad.,Certification Number IS.OUTER CASING far m,J6-cased wdb OR LINER(if a IkMde
EAOM TO DUMETE.R TmCKNE9$ I MATERIAL
Grady Poole Well & Pump Co., Inc. 0 « 9 Z R- 16 in. v
Company Name 16.INNER CASING OR TUBING sot Enufl dwed-low
332180 mom To DLAMETEk "DCKNEss MATk]OAI.
2.Well Construction Permit N: « fL sn.
Lest all appbcable well permms(,, Conan,Son,,✓anance,/nlernan.etc./
ft fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER SLAT Srmi THICKNESS MATERIAL
❑Agricultural ❑Municrpal/Public fL fL ie.
❑Geothermal S ) OResidential Water Su (single) ft ft in.
(Heating/Cooling -uPP1Y � PPIY( 8
❑IndustriaL/Commercial ❑Residential Water Supply(shared) IS,GROUT
PROM I TO MATERIAL EMPLACE.MENr MCIAOD6 AMOUNT
01ni lion 0 « 20 fL Bentonite Gravity
Non-Water Supply Well:
fL «
❑Monitoring ❑Rceoverv,
'a]ection we":
❑Aquifer Recharge ❑Groundwater Remedialion 19.SANDIGRAVEL PACK ifs ' able
PROM TO MATERIAL EMPWCEIs�\T ISD.THOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stornwater Drainage
D. fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fimaeb a4didosd sheen ifnecess
OGeothennal(Closed Loop) ❑Tracer FROM TO ]DESCRIPTION mlin b tolmau s,utraek OM urnininini,etc.
❑Geothermal(Heating/Cooling etu ) ❑Other(exlain under#21 Remarks) 0 6L 2 ft. Topsoil
Xal
r
4.Date Well(s)Completeu.J 5 WeI11D4 fL o fL k
od
52.Well Location: « ft
Peter Gitto ft. ft
Facility/Owns,Name Facility IDF(if appbcabk)
ft. «
Cheves Rd. Zebulon 27597 ft &
Physical Address,City,and Zip 21.REMARKS
Franklin
County Parcel Idcntrft t n,No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(ifwdl field,one lat/long is sufHciem) n
N W. 2�H./f•L� �CQ�LC.L(r' L J 'oc OILf
y 1 ,¢tare o f Cortified Well Contractor Dam
6.Is(are)the well(s): [OPermanent or ❑Temporary F�� } a By signing this form.I hereby cernfy that the wells)war(were)constructed In accordance
C with IJA.NCAC 01C 0100 or/5A N'CAC 07C.0200 Well Comnuermn Standards and that a
7.Is this a repair to an existing well: OYes or 0No copy ofthis record has been provided to the well owner.
Ifthis is a repair fell out known well construction information and explain the nature of the
repair under d21 remarks section or on the back oftMs 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 multiple thection or non-water supply wells ONLY it A the same ennvbr¢aon,you con
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /S6 (ft) 24a. For .411 Wells: Submit this form within 30 days of completion of well
Far multiple well.,list all depths,fdrgerenr(.ample-3a200'and 2n.100') construction to the following.
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
lfwate,level er.hove casing,are" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following.
I i.e.auger,rotary,cable,dire¢push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1&%
!I/ Method of test: BIOW 24e For Water Supply&Injection Wells:
13e.Yield(gpm) 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 GW-I North Carolina Depmnwent of Environment and Natural Resomcee—Division of Water Resources Revised August 2013