GW1-2021-01240_Well Construction - GW1_20210209

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Ronnie StanCll 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 0 ft ft
2283-A ft. it
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wdls OR DINER if a licable
FROM TO DIAMETER T1Ot3QVE.SSMINK
Grady Poole Well & Pump Co., Inc. 0 ft ft 6 ' in
Company Name 1&INNER CASING,OR TUBING(zeathermialdosed4eaul
GW-046174-2020 FROM TO DIAMETER THKNES ICS RIA MATEL
2.Well Construction Permit#: ft. ft in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER'S SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01mNonigation Water Supply Well: 0 k 20 ft Bentoni Gravity
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG attach additional sheets i£necess
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soiVradc type,Lrain size,etc
❑Geothernal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft Z ft Topsoil
4.Date Well(s)Completed: 1/27/2021 Well ID# 2 ft Z ft
Q ft © ft 0 Vw.1 �Vv rz
Sa,yell Loca'on: ft ft
ft ft.
Facility/Owner le Facility ID#(ifapplicable)
ft. ft.
5424 Pulley Town Rd Zebulon 27597 & ft.
Physical Address,City,and Zip 21.REMARKS
Wake 1788161821
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N `,it /r✓eN.I?,l.� SZi2>rLC� 01/27/202q
e w fiSigila' e of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporaryv
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
wi SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o p f rhis record has been provided io the well owner.
If this is a repair,fill out known well construction ittformation and explain the t�attyplpf t��1
repair under#21 remarks section or on the back of this form. c 1- 23� itg$i8am or additional well details:
r'A ma use the back of this a to provide additional well site details or well
gGv'- Y P�
S.Number of wells constructed: One q� AM35N'e,om�J&uction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same cAk ilttc&on,�ri�h
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a� (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths tf dgerent(example-3A@2000'and 2 a 100') construction to the following:
10.Static water level below top of casing: off/ (ft.) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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: Rotary construction to the following: i
(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) Method of test: Blow 24c.For Water Supply&Injection'Wells:
Also submit one copy of this form 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.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013