GW1-2021-01338_Well Construction - GW1_20210329

YELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: n
_ . 3 g
..N'ell Conlrnclor Information:
Grant Mason 14.VVAT1R ZONES
'-11 Contactor Name FROM IO DESCRIPTION
1254A $p fL CS H' I S J` %h
(L fL
R'dfConaactor Cettifcation Nwnber I&OUTER CASING fot,multi-euM.weW OR LINER`Iibk l. .
I.W. Poole Well & Pump Co. FRDa1 TO DIAMETER iHICKHE33 p xtP1161AL
,an,Name 8 In. .188I gals.
/ q�/ 16.INNER CASING OR TUBING t herrital aimed-too'
+fell Construction Permit k: f.-W'—U'- D. —Z12G FROM I TO DIAMETER THICKNESS MATERIAL
,;n appLcaMe well cm..vncrio„p,,mlu(t e.UIC.Cama e y.San Variance,uc.) R H. In.
-^Yell Use(check well use): ft. H. In.
`Water Supply Well: :17:SCREEN
FROM TO DIAMETER SLOTSITE THICKNESS SATERIAL
4.agnculmral OMunicipal/Public H. IL in.
_I%:emhermal(Head rglCootug Supply) )Residential Water Supply(single) n fL In,
?I ndussnaVConnnercial QResidenlial Water Supply(shared) 18,GROUT
tlm an Cn FROM TO MATERIAL EMPLACEMENTM METHOD A AOUNT
7'ou-Water Supply Well: ft. LO n' o e IU UV l
Jdlonitonng IDRccovcry R H. st
D,ieclion Well:
IT. M
I:\gwfar Recharge Groundwater Remedialion 19.SAND/GRAVEL PACK Ra 'gable
_ 'Aquif r Storage and Recovery Salinity Barrier FROM TO MATERIALI EMPLACEMENT METHOD
?Aquder Test [3Stormwater Drainage fL n.
—�Eepenlnental Technology ©Subsidence Control fL ft.
{iecthennal(Closed Loop) ©Tracer 20.DRILLING LOG.attach addifbnalandeta:Hisecuda' - .-
_+Geothermal(Hearin 'Conlin Return) Other(explain under N21 Remarks mom TO DESCRUPTION(cabr M1Wnm wlRak Nn sloe...
It n. Dip so
.'?ate Wells)Completed: -I_a I Well ID# f. H.
-.. 'Nell Location:
jYlC1t 13G. C✓,/I a n.
h"n„ner Name ` Fpaceility IDa(ifapplicabk) ft H. 1 2021
300S .4)e W k' y ,'43 Q fr -17i,leeyAi V,- fL It.
I al, Uri:
al Address,City.and Zip ft. n. -
�1fCA,lLI 3LRE6IARR$'
Parcel Identification No (PIN) Used hardened steel drive shoe.
-.-. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
dl Seld,one IaUlonp is tif6clem) 22.Certification:
3�.8b677a- N --79, 49&3S7 W aj jib - i- zr
-late)the weD(s)FK Permanent or Temporary Sigmtureof Cemfed Well Contraror Date
Bp signing rhea form,I hereby and,d r the,.dip),ran(were)mntrrucred in acrardaur,
s this a repair to an existing well: QYes or ©KNo n'dh 15ANCACO2C.0100am 15ANCACO2C.0200111,11 Conslr¢rion Standards and that
..r mpoir,Jill run kmm�u.ellcmurruuion i,ylorrna,ion and explain the namrr of live cape of this retard hor been provided to the well o,,e,,.
undo#21 r..nark, ,,im,or fin the hack of thin form.
23.Site diagram or additional well details:
Far 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
a,mlclon.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
Iled SUBMITTAL INSTRUCTIONS
Ialai,ell depth below land surface: I S (h-) 14a. For All Wells: Submit this form within 30 days of completion of well
- nvbiplr wells tier all depths Jdhrroo leamnpre-3@I00'nndl©too') construction to the following:
Static water lerel below lop creasing: Z-U (ft.) Division of Water Resources,IDformatiors Processing Unit,
aa./r,-d u atone caablg.nor"- 1617 Man Service Center,Raleigh,NC 27699-1617
Borehole diameter: 6 (in.) 24b.For infection Wens: In addition to sending the form to the address in 24a
=.'wall construction method: IW/"1 fy above, also submit one copy of this form within 30 days of completion of well
uger,rotary,cable,direct push,etc
construction to the following'.
Diaistun of Water Resources,Underground injection Control Program,
'�B WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636 E
.'i laid(gpnf) 15 Method of lest: Blow 24c.For Water Supply&Inieclion 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
b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environrnentai Quality-Division of Water Resources Revised L22-20 M