GW1-2021-07191_Well Construction - GW1_20211006

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ELL CONSTRUCTION RECORD(CGW-11. .. For Internal Use Only:
'Nell Contractor Information:
Grant Mason
ell Contractor Name FROM TO DESCRIPTION }.
4254A adtL 2Ls ft.
_ ft. -ft.
-Well'Contractor Certification Number 15i. ITT'EA;:G'5ING''to nii[tl Ealed;Ve'ell, f5R'.UTNER;Itik'"'U kbl2:t`:t_a.. ;
i'l.}tN. Poole Well & Pump Co. FROM TO 'DIAMETER THICKNESS MATERIAL
t It. S` It. 6 In. .188 galy.
:'ompany Name
,.l.�f1 7 ., ifitlNNE1t:CASffiG.l)RLUBING;:
.:.Well Construction Permit p: 9, / / FRO TO DIAMETER7niCKNE55 MATERIAL
isr all applicable well construction permits(i.e.UIC,Count),,Stale.Variance,etc.) ft. ft. in.
Well Use(check well use): It. ft. In.
Voter Supply Well: ::1,SCRERN , .:, r. ` _...,.,
_ FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
5r'�gricultural OMunicipal/Public t ft, rL 4•4 G� L 6 f/l�
Geothermal(Heating/Cooling Supply) xOResidential Water Supply(single) r IL ln.
itndustrial/Commercial [3Resideritial Water Supply(shared)
$Iri ation FROM TO MATERIAL EhiPLACETIENT METHOD&AMOUNT
idon-liaterSupply VYell: ft. '?.r ft.
Monitoring RecoverY. y fL GV ft.
!it
jection Well: ft. tL
_Aquifer Recharge Groundwater Remediation 19:?5ANDIG)3 YELPACK[Ua 'Uciible . �:_'
" ,;Aquifer Storage and Recovery [DSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
:,Aquifer Test OStormwater DrainagefL (f ft. �L2C Ovr
41Experimental TechnologySubsidence Cantrol fL rt.
)Geothermal(Closed Loop) [DTracer 2Q!I)R1J I tNG'LOG.until`eh.krldlilbn I:sH€et�:ifriteces a :_'
lGeodiermal(Heating/Coalin Return) Other(explain under 921 Remarks) FROM To DESCRIPTION jeolor,hardness,aolVrvek a rain aloe ete.
IL tt, n l
f r
Date Welf(s)Completed: ` Well ID# Z fL it. CA-
Well Location: fL
�, � rt ft.
7�'y/O 6�vncr Name 57/1 Facility tD#(iEapplicabk) ft. fL
db4_5 (_3 f°)`&r5 FG..r'ih i�+c- W P is f t /V C- rt. ft, v •�� e o�
ai,steal Address,City,and Zip ft. ft ��r}t
,- Parcel Identification No,{PIN) Used hardened steel drive shoe.
_ nay
--r,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
".,,ell field,one lat/long is sufficient) 22.Certification:
a N n ry Q 1 Y.2/' 2
s(are)the weli(s)Ox Permanent or OTemporary Signature of Certified Well Contra for Date
By signing this farm,I hereby certify that the ivell(s)was(were)constructed in accordance
a;this a repair to existing well: QYe5 or No Milt 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
'is is a repair,fill ate knawtt welt construction inform ation and explain the nature of the copy of this record has been provided to the welt of ter.
:rp,,vr under 021 remarks section or an the back of this farm,
23.Site diagram or additional well details'.
Tor 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
-0osuuC on,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
"''lied. SUBMITTAL iNSTRUCTIONS
Total well depth below land surface: 1� _) (ft.) Y4a. For All Wells: Submil this form within 30 days of completion of well
�r nmrhiple u:elis list all depths t(dWereiu(example.3@200'and 2 tr 100•) construction to the following:
!.Stntic water level below tap of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
-;rater lciW is abo,,e casing,use"+"
1617 1l4aU Service Center,Raleigh,NC 27699-1617
I.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Well construction method: y above,also submit one copy of this form within 30 days of completion of weir
construction to the following:
8.auger,rotary,cable,direct push,e(c:) o
-- Division of Water Resources,Underground Injection Control Program,
_011 WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rs{eigb,NC 27699.1636
a.?field( sIn BLOW
gl )_ Method of fast: 24c.For Water Supply&Injection Wells: In addition to sending the form to
k l ri{ I the addresses) above, also submit one coy of this form within 30 days of
Disinfection type: Amount: completion of well construction to the county health,department of the county
-" where constructed. i
•a+tf G\V-1 - North Carolina Department of Environmental Quality-Division of Water Resources r Revised 2.22-2016