GW1-2021-01327_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD (GW-1l
Well Contractor Information: .. '
Grant Mason
ell Contractor Name
4254A
-'- WelI'Canonclor Certification Number
j.W. Poole Well & Pump Co.
-wnpan) Name
well Construction Perndt a: E 2 ° -000 ]L/b
v all applicable well construction permits (i.e. UIC. County, State. Variance. ele.)
-.well Use (check well use):
water Supply Well:
Agricultural
lGeolhermal (Heating/Cooling Supply)
l I nd usl ri aliCommerc is 1
1ln:canon
Non -Water Supply Well:
Monitoring
tnjeclion Well:
Aquifer Recharge
'Aquifer Storage and Recovery
Aquifer Test
—iExpenmental Technology
1Geothennal (Closed Loop) '
Geothermal (Healin_ Coolin. Return
°Municipal/Public
EDResidential Water Supply (single)
Residential Water Supply (shared)
Recovery
°Groundwater Remediation
°Salinity Barrier
°Stonnwater Drainage
°Subsidence Control
°Tracer
Other ex lain under t/21 Remark
A
Date Well(s) Completed: 1— /3- - Well ID#
Well Location:
a-W n f{omes
--illn'0,ner Name
Facility IDe (if applicable)
3568 5 Po r a 5 fhli 12c� . r a� hopc .uc
; 7se z
steal Address,0 and Zip
ArmSl-J
Parcel Identification No. (PIN)
x. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field, one lat/long is sufficient)
35•8737(0] NR.o7a311
'a(are) the w'en(s)©xPermanent or °Temporary
Is this a repair to an existing well: °Yes or °° No
s IV a repair, fill ow known well construction information and explain the nature of the
wider 1121 remarks section or nn the back of /Us form.
'rot. Geoprabe/DPT or Closed -Loop Geothermal Wells having the same
--nstmcpon, only 1 OW -I is needed. Indicate TOTAL NUMBER of wells
.'.gilled
Total well depth below land surface: « L-/S (ft.)
,.,nhiple hells list a0 depths 1V different (trample. 3@200' and 41001
9. Static water level below top of casing: ZO (ft.)
Linter level is above casing, use "
IBorehole diameter: 6 (in.)
Poo r V
I Well construction method:
c auger, rotary, cable, direct push. etc.)
179fl WATER SUPPLY WELLS ONLY:
a.. Yield (gpnt) S6 Method of test: Blow
]b. Disinfection type: HTH Amount: 1 lb.
FROM
+1 a
For Internal Use Only:
11;0ATE YANKS'
FROM TO
aiS (L1 cc// n.
n TL
DESCRIPTION
15 O11TER CASING(fot.Mbltl-tued.Vreua)-OR:LINER ;(N3-' 11iibR)'.
THICKNESS MATERIAL
TO
( it,/ n-
DIAMETER
6 In.
188 galy.
16.1Nf4ER CASING OR TUBING rleerbit,hel eaed4birjij
DIAMETER
FROM
n.
TO
n.
THICKNESS
MATERIAL
fL
17; SCREEN
n.
in.
FROM
n.
n.
TO
(L
ft.
DIAMETER
In.
SLOT SIZE
THICKNESS
MATERIAL
In.
1& GROUT
FROM
D FL
M1
TO
zo n
n.
MATERIAL
EMPLACEMENT METHOD & AMOUNT
R
n
19. SAND/GRAVEL PACK (If appleible)
TO
FROM
fL
n.
MATERIAL
EMPLACEMENT METHOD
(L
n.
20.DRILLING LOG (Etta 1 idditham( Metall s
FROM
TO
2 n.
DESCRIPTION (color, batdns, aolVreck type, pain Sae, etc.)
7 (L
1' o fL
fL
l/0n.
ZZ)Sn.
n.
J4/12
fL
IL
n.
n.
MAR 2 9
n
n.
21. REMARKS
Used hardened steel drive shoe.
21. Certification:
Signature of Certified Well Contra tar
I - 13 -
2021
Date
By signing this form, / hereby certyly that the we/l(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the fomr to the address in 24a
above. also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Well6: In addition to sending the form to
the address(es) above, also submit one copy of this foci within 30 days of
completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22.2016