GW1-2021-01340_Well Construction - GW1_20210329

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':YELL CONSTRUCTION RECORD (GW-11 For Internal Use Only.
V,lAl Contractor lnformalion: . . r 3
Grant Mason 14.WATER NF.9
-11 Conaacmr Name FROM TO DESCRPTI ION
1254A I �q
fL L
Well'(7cle aor Ceuifmaticn Nu,nher 15.OUTER CASING forMultl#Raed.welt+.OR ti1NER:If 6 diabli
1.W. Poole Well & Pump Co. FROM o DIAMETER THICKNESS MATERIAL
n.Nan" + a n. 1 g In. .188 gals.
C5[[//,,
16.INNER CAB OR TUB therdul Hdeed•loii'
+tell Conslructimi Permit k: -w -a� SJ6_i?�)`77 v(/l FROM TO DIAMEfEP THICKNESS FIATERUL
�/i app[knble ne1l cmmrrocrinn pombs fi.e.UIC.County,Sole.Varfancq oc.) ft. n. In.
'+ell Use(check well use): It. n. In.
'-I atcr Supply Well: 17:SCREEN •'..•
FROM TO DUFIETER I SLOTSILE I THICKNESS I MATERIAL
aericukural ©Municipal/Public - n, fL
Oeethe mnal(II'm...g/Cooling Supply) K)Residential Water Supply(aingle)
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fL
!Indu<InaliCommercial Residential Water Supply(shared) 18.GROUP
{Img2tlan FROM 1 TO MATERIAL EMPLACEMENT METHOD L AMOUNT
-.`jilt-Water Supply Well: H. fL U/G 01 T
_j Hmitoring DRecovery fL n.
uriedion Well:
fL fl.
JAquifer Recharge IlGroundxater Remediadon
19.SAN0/GRAVEL PACK Lit• RcRble
Aquifer Storage and Recoven OSaluirty,Barrier FROM To MATERIAL EMPLACEF1ENr METHOD
:Aqui fer Test DSlormodder Drainage fL f6
�E:penmental Technology ®Subsidence Control fL it.
i Geothenual(C)osed Loop) ©Tracer 20.DRILLING LOG'.attach addltlonalshaeYQ neerosa
'Geethemnal(Heating/COoin Return) Other(exlain under 821 Remarks FROFf i0 DE6CRPTION Ieobr hnranae,selVrock gnln tlu eta.
—7 0, C
Date Well(s)Completed: 2-2 5"z Well IDR IL IL q�
'Vell location: IL 1�5 n. t
r
BSc &(ne-5 LCc_ rt. fL
--:ILt_-0r.naName facility lDNifeppliceble) fL ft. kia 021
'122( /i9a�5�i U<< w L.U. 2ehulei A/C fL ft. LI
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R�..sal Address Clry.and Zip 7S-/ / fL ft.
21.REMARKS: .I ` .'.. -.P
Parcel Idcnnficetion No.(PIN) Used hardened steel drive shoe.
.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
JI fie!d,ace ter/long is sufficient) 22.Certification:
35. S 2S 533 N - 7831 SO&6 W C_�'_
°I areltheold](s)OK Permanent or QTemporary. Slgnanuc of Cerfined Well Conhamr Data
Op signing Dais fmm,I hoe by terrify Dmr doe odl(s)on,(ioae)caarowo d in accordance
"=link a repair to an existing x'ell: ©Yes or ©K No ,vide 15A A'CAC 02C.0100 or 15A NCAC 0 .02001Ven Cormeacllorr Slaadards and that o
„ "P""fill mn On,"a,tell"anrunion irrforovarion and explain the nacre of elm copy a1this retard lens been provided to the o,11 olvner,
_.. ,.van A21 remarRs ocrimo or o,ire back ofrlds for,ro_
23.Site diagram or additional well details:
�i Geoprobe/DP'F or Closed-Loop Geothermal Wells having the saute You may use the back of this page to provide additional well site details or well
-lltmclon.only I GW-I is needed Indicate TOTAL NUMBER ofRvelis construction details. You may also attach additional pages if necessary.
.pled SUBMITTAL INSTRUCTIONS
Total well depth below land surface: 165 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
vW1,,1,•�.ede pnall deplhs if (,,oapte.3©100'and 2@100) conslruelion to the following'
'�.Slatic water level below top of casing: 20 (fl.) Division of Water Resources,Information Processing Unit,
orcr kvd is adore casing.cue "� 1617 Mail Service Center,Raleigh,NC 27 6 9 9-16 17
Borehole diameter: 6 n.) 24b.For Infection Wells: In addition to sending the forth to the address in 24a
k/�n� I above, also submit one copy of this form within 30 days of completion of well
'.Tell cmistructims met lad: J IT construction to the following:
- zugcr-rotary,cable,dircq push,ec)
Division of Water Resources,Under round ID')action Control Program,
LLS ONLY: g
"vR AVATER SUPPLY WE
1636 Mall Service Center,Raleigh,NC 27699-1636
field tgpnl) Method o[tesh Blow 24c.For Water Supply&Injection 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
o.Disinfection type: Amount: completion of well construction to the cowry health department of the county
where constructed.
i North Carolina Deparhncat of Environmental Quality-Division of Water Resources Reviscd 2 22 2016