GW1-2021-01337_Well Construction - GW1_20210329

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!JVELL CONSTRUCTION RECORD (GW-11 For internal Use Only: a
\?ell Contractor Information:
Grant Mason WATE 7AN
-III Contractor Name FROM TO DESCRIPTION
254A )lz ft a'f ' L Co f+T
taell'Contranor Certification Number I F„t OfL I �f It
IS,OUTER CASIN,,GG fpfrt ltl•kaled mlb OR LINER-Vo- tleihle
\LW Poole Well & Pump Co. FROM TO mAhiETER i1fICKNE55 IVHIAL
Name +1 ft I W ft. 6 m• .188 gals.
�� 11,INNER CASING ORTUEING therrdil closed4tem)
''--ell Conslruelmn Perndt a: V �^1 w 1 (� I �A-d FROM I TO WAa1ErER THICKNESS M1IATCRUL
,d oppF oble„e11 co,unnclimi pe.rnife(l.e.VIC.eoanm,stare.variance,err.) ft I R, to.
�10i Use(check well use): ft I ft. In.
`•Tatcr Snpply Well: 17.SCREEN •.
FROM TO DIAMETER SLOTSIEE THICKNESS MATERIAL
AL
©Municipal/Public R. fL In.
_ Ceothermal(Heeling/Cooling Supply) ®Residential Water Supply(single) n. rt. in.
[IndustriaVCanmercial ©Residential Water Supply(shared) 11.GROUT
ilolRalion FROM IO I MATERIAL EMPLACEMENT METHOD 6 MIOUNT
den-W'atcr Supply Well: r1 ft aO rL j_tI'J01 .
_
Nantloring 1313ecoven V ft ft.
+iection Well:
ft u.
\gmfer Recharge []Groundwater Remediation 19.SAND/GRAYELPACK VR RcRble
.Aquifer Storage and Recoven ®Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'.Aquifer lest [3Stomlwaler Drainage ft. ft.
-�H\pertmental I ec]mologe ©Subsidence Control [L A.
.Ciecthenmal(Closed Loop) ©Tracer 20..DRILLING LOGartr sddltlbtulbheeti VReceesa
—a-Ter-thermal
FROM TO DESCRIPTION actor hvdnm,eolVrvck tinelu em.
+(,eethennal(Heatin iCoolin Room) Other(ex lain under N2l Remarks)
- � rL � it Itl C2
%ale Wells)Completed: a g Well IDk It ft J ca, �CL
LIell Location: 7 4 IL t iL f� �•�.
rx�
ft IL
-dln, O,vner Nome (� Facility]DO(ifapplicable) f6 n. p p q1
(0 ��' I' tirvh of o.�� h', � i� �r� ft n. IiH� 2 7
w ft.
,.al Addres,Clty.and Zip
21.REMARKSr I'
Parcel ldowficetireNo (PIN) Used hardened steel drive shoe. �-
.1-a ti bade and lougilode in degr'eeshninutes/seconds or decimal degrees:
-.dl fmld,one let/long is suffidenq
22.Certification:
355G3181f N -�8.�5?0�152 W
r(s,e)lire rvell(s)E% Permanent or Temporary Signourc of Certified Well Cernoutter Date
by nlir,g his Pro,I hereby c,,I fy D,m the r.dlfrJ,vm pvereJ connraaed oi acrordance
this a repair to air existing well: QYes Or R©No mlth 15A NCAC 02C 0100 or 15A NCAC 02C 0200 Nell Conuracl ca,51m,dards arid 0ov o
n a repofgill oat Anwcn "If canon¢don 1,tJou,mtlon and ,plain fire nature of the copy oflhis record has been provided to the,vell ra ner.
corder ell rIavrAl seo.o„ar ai fire bock of rhu for,n.
23.Site diagram or additional well details:
or Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of[his page to provide additional well site details or,yell
—nsuuyn.only I G%V-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessarv.
��`d SUBdRTI'AL INSTRUCTIONS
7oml well depth below laud surface: Li A)
24a. For All Wells: Submit this forum within JO days of completion of well
n�aaple,reltr Udall deprlu Jd/j rnv(esarnple.3Q100'nndT@100') construction to the following:
Static wafer level below fop of casing: al� (ft.) Division of Water Resources,Information Processing Unit,
e,fere/,,ahoy e"ong,ase "- 1617 Mail Service Center,Raleigh,NC 27699-1617
L Borehole diameter. 6 (in}.) 24b. For Inieclion Wells: In addition to sending the form to the address in 24a
ll constructiot,meflmd: 1C d Y0.r\.I above, also submit one copy of this form within 30 days of completion of well
rotary,ablq diced push,etc.)
construction to the following.
DlaislOD of Water Resources,Underground Injection Control Program,
")C tM1'ATER SUPPLY WILLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ield(gpin) S Method of test: BIOW 24c.For Water Supply &In iection Wells: In addition to sending the form to
HTH
1 lb. the address(es) above, also submit one copy of this form within 30 days of
��.Disinfection type: Amount: completion of well construction to the cowry health department of the county
where constructed.
`: North Carolina Department of Envirommeaal Quality-DiVaTry of Water Resources Revised 2 22-2016