GW1-2021-07204_Well Construction - GW1_20211006

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'VYELL CONSTRUCTION RECORD GW-1. For Internal Use Or_dy: ) '
"yell Contractor Information:ell,
zei4 WATE _Z0N
':dl Contractor Name O FROM TO DESCRIPTION '
SAA ! ''Z5 ft.
ft.
f�
WelfConuaclorCenificalionNumber ,0� � �41 %(,4 ft. -ft.
is0 1N. �nJl-n+� FROM Ek::GACS�ING;foEliifil Ea4ednelLi;fSR.liINER lt6" lireblei .:
Poole Well & Pump Co. t,�.` o� +1 TO DIAMETERJIn.
THICKNESS hATERIAL
npanyName - rL Im ft. g .188 galv.
•` ]� :1G,;INNER:CASINGOIL7:UBING' 'thefitial:closed=lbti -:+� '
..'Well Construc(ion Pernilt N: G i l'/ FAOht TO DIAMETER THICKNESS I MATERIAL
i rr all applicable melt cartsm'uclion permits(i.e.UIC.Cotrrtty.Slate,Variance,etc.) f4 ft. In.
','yell Use(check well use): ft. ft. In.
.`rater Supply Well: 11i Sum:
_
-" F_AOh1 TO DIAMETER SLOTS ZE THICKNESS MATERIAL
gAgriculhnzl E]Municipal/Public ft. ft. in.
AGeothennal(Heating/Cooling Supply) xoResidential Water Supply(single)
ft. fL In
Industrial/Commercial E)Residential Water Supply(shared)
-)irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT.
i!on-Water Supply Well: e fL �� ft.
_s PAonitoring Recovery ft. ft. P
22
,m.lecnon Well:
lA uifer Recharge fL ft.
q g ft.
'v�quifer Storage and Recovery Salini Barrier nFRONI
=PACII ;.;_ry EhfPLACEh1ENTMETHOD
`Aquifer Test0Stormwa(er Drainage__�+E�perimental Technology Subsidence Control
DGeothennal(Closed Loop) [- Tracer ;2i1;DIEILI NGL'OG attachpddltiondl'sti[•clI'Ifneee35if',`
+Geothermal(Heating/Cooling Return) nOther(explain under N21 Remarks FROM TO DESCRIPTION(color hardness,aollfrock type raln size etc.
o ft. I ft.
?fate Well(s)Completed: z i J L� Well IDN 2' fL ft.
J. d
/101
tl+ell L9cati n: C tL L7.93 ft•
-.;iliiy/0svner Name Facility IDN(if applicable) ft. ft.
ft. ft.
',,sical A— ddres City,and Zip a fL ft.
Parce identificationNo.(PIN) Used hardened steel drive shoe.
b.Latitude and longitude in degrees/tnlnutes/seconds or decimal degrees:
::'ell field,One 131/long is sufficient) �y 12.Certification:
yo � 7 N h O]a,'S W
'(are)the n'ell(s)E)Permanent or OTemporary Signature of Certified Well Contra for ate
0y signing this form,I hereby cert�that the wells)was(were)constructed in accordall e
a ibis a repair to all existing well• nYes or E]No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Htell Construction Standards and that a
phis is a repair,fill out known well construction h jonnalion and explain the nature of the copy of this record has been provided to the well owner.
::nair wider d21 remarks section or on the back of this form.
23.Site diagram or additional well details:
"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
HnsuuCljOn,only I GW-I is needed. bidicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
frilled: I
SUBMITTAL INSTRUCTIONS
Total well depth below land surface: � L.•V� (ft.) 1
'.ter nudriple„reftr list n!i depthslJderein(example-3(?a 100'and 1 a/00') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
".Static water level below top of casing: ZJ (ft.) Division of Water Resources,Infor motion Processing Unit,
1�.nter Ienel 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
=.Well construction method: /v/?v above, also submit one copy of this form within 30 days of completion of well
e.auger,rotary,cable,d'vect push,'etc.) - -construction to the following:
Ofl`SWAYER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
yield(gpnl) �Z" Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the torn to
_
HTH 1 Ib.. the address(eS) above, also submit one copy of this.form within 30 days of".b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016