GW1-2021-07192_Well Construction - GW1_20211006

>YELL CONSTRUCTION RECORD{CAW-1) .. For Internal Use Only: "
'.Nell Contractor Information:
Grant Mason 14:,„A3E `ZUN
Contractor Name FROM TO DESCRIPTION
4254A NO rL rt,
l�'O tL % .ft.
,.rt-tVell'Contracror Certification Nmnber
Well & Pump
r� `:15t,',O.ti'I'.RR:CASING:tdf+.liiHlii.'..l:a.t't':;igdCi.i)R!IiIIlER If;6�.,.11id(i6tc dt::°,_..
N.W. Poole
oole V V ump Co. FRO41 TO DIAMETER THICKNESS MATERIAL
+ rL
ompant Name rt. 6 in. .188 gaiv
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�b�st>Z� :.1b;�I1VNE1t:GASINO.OR_'T.UBINIC tbe"'"" riitnletiiaed:lbo .,,.: ..:.
Nell Construction Permit N: FROM TO DIAMETER THICKNESS MATERIAL
AV all applicable+yell construction permits(i.e.U1C.Country,State,Variance,etc.) fG H. in.
OVell Use(check n'e11 use): ft. In.
=valet Supply}VeII: :11:SC RE I3N a: a
FROM TO DIAMETER SLOTS ZE THICKNESS MATERIAL
Agricultural nMunicipallPubiic - n. fL In.
JGeothermal(Heating/Cooling Supply) MResidential Water Supply(single) It, rL In.
ndustrial/Commercial OResideitiai Water Supply(shared)
;!Iri anon FROM TO MATERIAL % EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL / ft. /�
pMonitoring Recovery fL V ft.
Injection}Veit:
fL fL
(Aquifer Recharge Groundwater Remediation
,Aquifer Storage and Recovery Salinity Battier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL tt•
@Experimental Technology Subsidence Control fG ft.
OGeothenmal(Closed Loop) Tracer ,:2t11I)ItILItKG"Lot;'attach Eadlil5i
FROM TO DESCRIPTION(color,hardness,solifroek type,train s1te etc.
IGeothermai(Heating/Coolin Retum Other(explain under a21 Remarks fL 2 it. L
j
Date}}'ell(s)Completed:`a�--�--� Well IDft fG rt. Y
�r.Weil Location:
rL rt.
/Y�/1`�t.°'�)f fL ft. • +`�`�
'xdlit lQ++nor Name Facility 1D0(itapplicablt)
'�t;sical Address,Cityt and Zip t4 fL - JEEP
: 1R>friARKS! ,:: .�r r.,;'.. - .«:;•. . ,. .`.I-::' .
Used hardened steel drive shoe
u Parcel Identification No,(PIN)
o La titude and longitude to degreeslminuteslseconds or decimal degrees:
ell field,one Ia`Vlong is sufficient) 22.Certification:
(are)thewell(s)OPer•manent or OTemporary Signature of Certified WellCantrator Date
Vy signing this form,I hereby cerlify that the)vell(s))vas(were)constructed in accordance
Is this a repair to an existing well: Yes or No )vith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandards mid that a
is a repair,fill nut known well construction information and explain the nature of the copy of this record has been provided to the welt owner.
!:imir under#21 remarks section or oil the hack of this form.
23.Site diagram or additional well details4
?or 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
nstnic on,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
Hled' SUBiv MAL INSTRUCTIONS
>,Total well depth below land surface: (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
nr"Whiple)cells list all depths lfd fferent(example.3Q200'and 1Q)00') construction to the following:
'.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
•wa.!e,level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
v
`Well construction method! construction to the following:
auger,rotary,cable,direct pusir,etc.) e e
- Division of Water Resources,Underground Injection Control Program,
Ds;WATER SUPPLY/WELLS ONLY: 1636 Mail Service Center,RaIelgh,NC 27699.1636
a.Yield(gpm) Method of test:' Blow 24c.For Water SupDiy&Infection Weld: In addition to sending the form to
1 lb the address(es) above, also submit one cppy of this form within 30 days of
Disinfection type: I H Amount: completion of well construction to the county health department of the county
-' where constructed.
ti r
_mn OW-1 - •. Nosh Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016