GW1-2021-00347_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD For Internal Use ONLY
%s form can be used for single ar multiple wells
1.Well Contractor Information:
Ronnie Stancil 14.
FR WATER ZONES
PROM TO DESCRDrnON
Well Contractor Name 0 fL ft /✓)
2283-A fit rL ko
NC Well Cmuscum Cenifinuon Number 15.OUTER CASING furauld-cnedwdla OR LINER(itim ' ble
FROM 1 TO DIAMETER I THICKNESS I MA1111mIAL
Grady Poole Well & Pump Co., Inc. 0 Inc I 9 a 16 is
Company Name 16 INNER CASING OR TUBING eothermal slmM-Ica
160886 FROM TO DIAMETER TmCRNF SS MATERIAL
2.Well Construction Permit#: 88 D• fL ins
List ail applicable well permits h e.C'mn i State,Variance,Inlecnon.etc./
ft. R in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DUMEnsa SLOTSIZE T/HC'KNFSS MATERIAL
R 2 n
❑.4gricul[urel ❑Municipal/Public
❑Gcothennal Heatm Coolin Supply) ®Residential Water Supply(Single) ft. ft in
( 4/ 8 PPY PPY( 8
❑Industrial/Commercim OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL RMPLACEMEfT MLTHODd AMOUNT
otni ation 0 a 20 a Portland& Gravity
Non-Water Supply Well:
a IL
R .
❑Monitoring Ott:overy Screenings
'
Injection Well: IL O.
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPG(:lc T METHOD
CAquifer Storage and Recovery []Salinity Banner rL in
❑Aquifer Test ❑Stormwster Drainage
ra D.
❑Experimental Technology, ❑Subsidence Control
20.DRILLING LOG smash additional sheen ifnrceMa
❑Geothermal(Closed Loop) 13Tracer mom To OF1SQtH`n0N color eirdnm so umsx ty,, vian me de.
❑Gcothermal Hearin Conlin Rent ) ❑Other(explain under 421 Remarks) 0 ft 2- In. Topsoil
D/ /� �' 2 ft R c/
4.Dart Wells)Completed. Well ID#
a s /J fL A ry w y k•
5a.Well Location: rL It
Roger Johnson m a
Facility/(Amer Name Facility Joe(dapplicable) ft. ft
614 Driver Rd. Middlesex 27577 « R.
Physical Address,City,and Zip 21.REMARKS
Johnston
Counry Parcel Idera fitmum No(PIS)
5b.Latitude and Longitude in degrees/minutes/secouds or decimal degrees: 22.Certification:
(if well field,one leulong is sufficient)
Signature of Certified Well Covvsctcr Da
6.ls(are)thewcll(s): [OPermnnent or ❑Temporary
Hy s,gnmg this form, I hereby certify that the well(sJ cans(were,comtructed in aroordawe
44A NCAC•02C.0100 or 15A NCAC 02C 0260 Well Cmvuucoon Standards and that a
7.Is this a repair to an existing well: OYes or FlNO t ^ o this record has been provided to,he well owner
If this is a repair,fill out known well consuncuon information and explain the naAu a or the
repair under 021 remarks section or on the back of this 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 injection or non-water supply wells ONLY with the same costrnuedon.you can
submit one form. I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 'b /�`r (ft) 24a. For A8 Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example.3@200 and 2@100') construction to the following.
10.Static water level below tap of casing: o (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For lniection 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: ry construction to the following.
(i.e.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) !'��,o Method of test: BIOW
r 24c.For Water Supply&Injection Wells:
`
Also submit one copy of this forth 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.
Fam GW-1 North Carelim Department of Envvovmem andNarmai Resources—Division of Water Resources Revised August 2013