GW1-2021-01351_Well Construction - GW1_20210329

?YELL CONSTRUCTION RECORD (GW-11 For Internal Use Only
*'ell Contractor Information: r l�f ' ✓1 '
Grant Mason 14:WATER EON _
oll Convaaor Name FROM 20 DESCRIPTION
(254A I �I ft I P GP kn
fL If.
"-Well'Convenor Certification Nmnber IS,OUTER CASING(foe add-boaad Gelb ARLINER.it RvEk'
`).W. Poole Well & Pump Co. FROM TO DIAMETER SBICKNE33 MATERIAL
�J/
+ rt. E H. 6 In. .188 gals.
'1 ( 7/17— ZEJ—' .16.INNER.CASING OR TUBING. - hefmalelured42W-
•\'ail(.onsflvctiOn Permit p: ���U ( // c� FROM TO pIAMETER inICKNEaa MATERIAL
'itrl"Lcabla i,e11 corunucrlmr permltr(i<.VIC-Cmaur.Si,o ,Va6ance,'10 fL ft. In.
'3'ell Use(check well use): M n. In.
ater Supply Well: -17:SCREEN
-- FAOM1I TO p1AMETER SL02512E t1fICKNE3S MATERIAL
?:Icncultural Municipal/Public p, ft
,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n. I fL
;Industnaf/Commercial ©Residential Water Supply(shared) 18.GROUT
}Im¢aIICn F
ROM EMPLACEMENT METHOD h AMOUNT
`Ion-Water Supply Well L)�NonimringRecovery lA uifer Rechar e
4 g Groundwater Remedialion ,19.SAND/GRAVEL PACK(if a -Ueable
;\gmfer Storage and Recover} QSalinity Banner TaoM1f To MATERIAL I EMPLACEMENFhlE1R0D
--'Aquifer Test ©Stonnwaler Drainage fL fL
_jV,verimental Technology Subsidence Control fL U.
tGemihennal(Closed Loop) Tracer -20.DRILLING LOG'anaeh addithavilibeen if necessR
Ir rithermdl(Heating/Cooling Return) nOther(explain under 021 Remarks FROM TO DESCRPiION(nlor 6ardn,aa,volVrak nlntlm etc.)
(J D. C_
-9ate Well(s)Completed:3 5 Z ( Well IDR 7fL 2 ft.
vVell Location: / --7 fL %
- D. U
fl77l�A7I �ct /d Wf.il M ft.
--dM1n O,ner Name Feciliry[DO(ifapplied,k) fL ft.
30i3 A/24/ Wctlk,'nS Ln. Pct./e,/-4 y6_�27!11 n. R 2 9 221
_I Addr,s,Ott,and zip a n.
1 AI(ti l(A_ 21:REMARKS
fly Unit
V Parce]ldentifieamNo.(PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-•ell f,K one Iv1ong is srRi6,ot) 22.Certification:
35.gv122� N - 78.�i53�� W
=tare)the a'eH(S)O( Permanent or ©Temporary Signime,crCerfified Well Contrafor Date
_ 0) algniog rhl fvo,I hereby certify Dmt on rWIDI wus fxzre)c ovo,,s d In accord.,,
s this a repair to an existing well: DYes or ©K No mirh 15A NCAC 02C 0100 or 15A NCAC 02C 0200 RWI Cominrcrie,r Smndnrdr and tlmt n
a,#21f,,mu krmu+ivo,rot he htion ino,sjo,mr ande_eplaln the nature aJthe ropy aJtlds record hatbeen pravtded ro the rreflowner.
...,:unanr e2/rernmRs seaimr or mr he hod o/rhisJarrn,
23.Site diagram or additional well details:
er 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
"nslruclon,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
Iled
L// SUBMITTAL INSTRUCTION
Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of Nell
nndrlpla Ards nn ou dapor Iifd rent re+anpt, 3@200 and 2@a100')
construction to the following:
".Static water level below top of casing: 2O (ft.)
/e,rl Ir Division of Water Resources,Information ProcessingUnit,
me. ovove"Sing,rue" 1617 MaR Service Center,Raleigh,NC 27699-1617
3orehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
-. ':Tell construction method: f'f-.(- y above, also submit one copy of this form within 30 days of completion of well
auger,romr.,cable,direct push,etc.) construction to the following:
`2R WATER SUPPLY WELLS ONLY: D11 lion of Water Resources,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 27699-1636
''t irld(gpin) Method of test: Blow 24c. For Water 5upply&Indection Wells: In addition to sending the form to
- HTH 1 lb. the address(es) above, also submit one copy of this forth within 30 days of
Disinfection l3'Pe Amount: completion of well construction to the county health department of the county
where constructed. -
North Carolina Depamnent of Envirormental Quality-Diciu I,r of Water Resources Revised 2-22-2016