GW1-2021-01173_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronnie Stancil
Well Contractor Name FROM TO DESCRnPTION
2283-A 0 1
NC Well Contractor Certification Number
35`.411TE1tG t'r X�aitilu ".>. h0a t11C=1�PttPiit+. , eabit-,
Grady Poole Well & Pump Co., Inc. FROM TO DIAMETER THICKNESS MATER AL
Company Name 0 ft
l®� ra
t��= L'ti; 11+ID ' 1�D elictoaed�laio`
2.Well Construction Permit#: GW-022569-2019 FROM TO I DLIMETER I THICKNESS I MATERIIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft- 6 in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 1 'SCitl+t t.
FROM I TO I DIAMETER: SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. g, in.l
❑IndustriallCommercial ❑Residential Water Supply(shared)
Olffigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. Bentonite Gravity
❑Monitoring ❑Recovery IL ft.
Injection Well:
fa ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENTN=OD^v
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer777
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks FROM I TO DESCRIPTION color,hardnes%soWraeh type,grainaim eta
0 ft. ft Topsoil
4.Date Weil(s)Completed: 02/11/2021 Well ID# Z, ft. 46 ft. C
5a.Well Location: gd H• Zed ft. 4P
Miguell G. Rodrigues ft. ft.
Facility/Owner Name Facility M#(if applicable) ft. fL
3405 Hardwood Dr. Apex .27539 ft. ft.
Physical Address,City,and Zip IL ft.
Wakex„1A
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N w 1&y4� ' 2/11/2021
6.Is(are)the well(s): 111'ermanent or ❑Temporary Signature of Certified Well Contractor ! Date
By signing this form,l hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the , _ q� °u aY use the back of this pagelto provide additional well construction info
construction,only I GW 1 is needed. Indicate TOTAL NUMBEI€�'wel yy, u`" �T:Over'in Remarks Box),You may also attach additional pages if necessary.
drilled:onB h ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Submit this-GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifjerent(example-3@200'and 2@100') ,2 ?i3i 0 '24 Ar All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below to of Iasi li"sCil' `'`"
If water level is above casing,use^P^ ;u; f ^`•Y�iiftir�mation Processing Unit 16171SISC,Raleigh,NC 27699-1617
6 24b.For Injection Wells:Copy to;DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary
24c.For Water Su and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county envrronmen ea department of the county where ms
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells rodacin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Blow Permit Program,1611 MSC,Raleigh,!,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Lb.
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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