GW1-2021-00794_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Ronnie Stancill 14.WATER ZONES
4 FROM T DESCPJMON
Well Contractor Name 31, T ft
2283-A it. _7Cq ft.
NC Well Contractor Certification Number 15.OUTER CASINEfLor mull-cased LMER(ifav (cable
FROM TO )
I DIAMETER THICKNESS MATERIAL
wells YKRT Grady Poole Well & Pump Co., Inc.
ft 16 0 ft vc-
CompanyName ti` 16,INNER CASING OR TUBING(geotlitrinalclosed-loop)
GW-047121-26i6 FROM I TO I DIAMETER I THICI NESS MATERIAL
2.Well Construction Permit#: ft f" in. I
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) & & in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft ft. in. I -
DGeothermal(Heating/Cooling Supply) ®Residential Water Supply(sin le) ft. ft.
in
OIndustrial/Commercial OResidential Water Supply(shared) IS.GROUT
FROM I TO -MATERIAL EMPLACEMENT METHOD&AMOUr-Tr
OIrrigation 0 it 20 iL Bentonite Gravity
Non-Water Supply Well: ft. ft.
OMonitoring ORecovery
Injection Well: ft. ft.
OAqiufer Recharge OGroundwater Remediation 19.SANID/GRAVEL PAC Ofavolicable)
I FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Storage and Recovery OSalinity Barrier ft ft.
DAquifer Test OStormwater Drainage ft. ft.
OExperimental Technology 0 Subsidence Control 20.DRILLING LOG(attath additional i Isheets.ifnecessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIMON(color,hardness,soil/rock type,gmin size,etc.)
DGeothermal(Heating/Cooling Return) 13 Other(explain under#21 Remarks) 0 ft. ft. Topsoil
ft.
4.Date Well(s)Completed. Nell E[)# ft
ft r-C ft.
JV.F %
5a.Well Location: ft. J;C' ft.
Rex Harris ft. ft
Facility/Owner Name Facility lD#(if applicable) ft. ft.
2425 New Bethel Church Rd Garner ft ft
Physical Address,City,and Zip 21.REMARKS
Wake 1629806354
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattiong is sufficient)IN W z
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the hack 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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /_60 -(ft.) 249. For All Wells: Submit this fbrm within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
,gyp f
10.Static water level below top of easing: Division of Water Resou rces,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 Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this,form within 30 days of completion of well
12.Well construction method: Air Rotary 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) If Method of test: Blow 24c.For Water Supply&Injection Wells:
Also submit one copy of this form!within 30 days of completion of
HTH well construction to the county health'department of the county where
13b.Disinfection type: Amount: 1 Lb. constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013