GW1-2021-00572_Well Construction - GW1_20210224

WELL CONSTRUCTION RECORD For Internal Use ONLY This form can be used for single or multiple wells
1.Well Contractor Information: pr...1�E6\f .�J
Ronnie Stancil RE 14•WATER ZONES
FROM T DFSCRIPOON
Well Container Name fL ft
2283-A F`ta 2 d 20 0 6 0
ft ft.
NC WtH Contractor Certification Number (ntofmation PfoC2S$Ifl(�Un 15.OUTER CASING forma ti-caand wells)OR LINER fit a,, able
DWR SectlOn FROM TO DIAMCI'P.N THICKNESS MATERIAL
Grady Poole Well & Pump Co., Inc. 0 fL iL 6 is 1 Teo i L
Company Name 16.INNER CASING OR TUBING eotherrmI closed-too
W-3184 FROM TO DIAMETER TIOCKNMS MATERIAL
2.Well Construction Permit N: (L fL tic
List all apph ahle well permits(i.e.Counry,State, Variance,/n)ecnon,etc)
ft fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIAMETER SLOT SIZE THICKNESS MATERAL
❑Agricultural ❑Municipal/Public ft. (t
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R' R. r
n.
❑Industrial/Commercial ❑Residential Water Supply(shared) ULGROUT
FROM I TO MATERIAL f:MPI.ACEMENT METHOD 6 AMOUNT
DIrrigation 0 fL 20 h- Bentonite Gravity
Non-Water Supply Well:
ft tt
❑Monitoring ❑Recovery
Injection Well R fL
❑Aquifer Recharge DGrourodwater Remediation 19.SAND/GRAVEL PACK if. It. It
Aquifer Storage and Recovery []Salinity
TO MATERIAL EMPLACEMENT METHODSalinity Barrier it. it
❑Aquifer Test ❑Storrtrwater Drainage
ft. ft
❑Expesureital Technology ❑Subsidence Control
20.DRILLING LOG an.ch ddidotsal sheets if necem
OGe rthermal(Closed Loop) OTracer PROM TO DESCR ON color hardn wiVrark eta
OGeothermal(Heafin Coolie Return) ❑Other(explain under k21 Remarks) 0 fL ft Topsoil
v/Zj2o21 iL R.
1.Date Well(a)Completed: Well ID$1
� rt. ft'
5a.Well Location: ft R.
Peter Gitto
ft fL
Facility/Owner Name Facility IDa(ifappfic.1,k)
ft. ft.
2576 Conyers Road f ft
Physical Address,City,and Zip
2 MA /
Granville 9,mil, x
County Parcel Idemi5cation No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient)
N W iQgy�y� e:ytt4� 01V)— ,/2021
Signature of Certified Well Contractor Date
6.Is(ere)the well(s): laPermanent or OTemporary By signing this form,L hembv cert6 that the well(./ was(were)constructed in accardmice
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well C'oasaucrion Smrxlar is and that a
7.Is this a repair to an existing well: DYes or 91No copy of this rerord has been provided m the well owner.
Lfabs is a repair,fill out known well construction information and explain the nature of be
repair under-".2/remarks section or on the back ofthis 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 mutable injection or non-water supple wells ONLY wish the same emu wetion,you con
submit one)rm t/^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lc'different(example-3@200'and 2@ 100') construction to the following'
10.Static water level below top of casing: a (ft) Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,are 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Injection 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.
lie,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blow 24c.For Water Supply&Injection Wells:
Also submit one copy of this force 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-1 North Carolina Deparanent of Environment it Natural Resources-Division of Water Resources Revised August 2013