GW1-2021-07337_Well Construction - GW1_20211006

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ryYELL CONSTRUCTION RECORD (GW-1) For Internal Use Drily. '
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3;a'ell Contractor Information:
Grant Mason
14 WATE ZONES
yell Contractor Name FROM I TO DESCRIPTIONI.
=l254A
ft. fL
C Well'Contractor Cenifrcation Number
`i 15c:C2i1TERi:CA51NG;focaii6ltled:wdl§;k'f.RhINER�Ifh..:.'Ilci6le a�::....... r
H.W. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS I MATERIAL
'bmpany Name
+ rL `-2 ft. g in. .188 gals.
16:.INNER.t ASllVG OR:7ITBIPIG%"erilhciiiial closedlbo
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Well Construction Permit N:&-L.,- O lbydS-Zo1 g FROM TO DIAMETER THICKNESS MATERIAL
:rst all applicable well consuvrclion permits(i.e.U1C.Counry,State.Variance,etc.) ft. ft. In.
ell Use(check well use): fL ft. In.
^'zter Supply Well: s:17iSCREEN:
FROM TO 1 DIAMETER SLOTSIZE 'THICKNESS' brATER1AL
;Agricultural [DMunicipal/Public fl. fL In. vC
(Geothermal(Healing/Cooling Supply) xDResidential Water Supply(single)
ft rL In
..Industrial/Commercial [3Resideriliai Water Supply(shared)
§Irtl anon FROM TO MATERIAL EMPLACEMENT METHOD&AbtOUNT.
!on-Water Supply Well: Q iL 20 ft
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Monitoring Recovery fL ft.
e;r.iection Well:
kA uifer Recharge ft. ft
9 g DGroundwater Remediation
fA.quifer Storage and Recovery Salini Barrier '14:SANDLGR0 L_PAGK:iGa 'llcable ;;.
lY FROM TO MATERIAL I EMPLACEMENT METHOD
_`Aquifer Test E)Stormwaler Drainage ft. iL G v
__ilExperimental Technology Subsidence Control ft. fl.
i
'Geothermal(Closed Loop) [3Tracer ;2011)RILLiNGLOG;'iittachtiddldbti,jl:"slf€ei�llfReci35n"'
_ Geothermal(Heating/Cooling Return) Other(explain under f121 Remarks FROM TO DESCRIPTION color,hardness,sollhoek rain size,ate.
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+.Date Well(S)Completed: L -20-Z I Well IDN 02ft. ` rt• CA,
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Well Location: ft. ft. ( � LI
Pal k f y yCrJO rL n.
"aciliry/Owner Name Facility iDll(tfapplieable) rLrl.
n. ft. T
:r.sical Address,City,and Zip fL ft. Unt1
Ce sa�9
_ �W(,L 2i REMAItKs!
Parcel Identification No.(PIN) Used hardened steel drive'shoe.f
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field,one W/long is sufficient) 22.Certification:
Np W -✓
`(are)the tvell(s) % Perntanertt or DTemporary Signature of Ccrtffted Well Contra for Da e
Dy signing this form,I hereby ceri fy that the well(s)was(were)constructed in accordance
s this a repair to an existing well: [DYes or E)No with ISA NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
thi.T is a repair,fill mu known well construction information and explain the nature of the copy of this record has been provided to the well onhrer.
::Pair rider#21 remarks seclion or on the back of dris fornn.
23.5ite diagram or additional well details:'
-nr 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
nsuuc on,only 1 GW-I is needed. bldicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
illed:
'/ SUBMITTAL IN TRUCTIONS
=,Total well depth below laud surface: �j nudliple wells list all depths if dii ferew(example-3@200'and 1Q100') (ft-) 24a. For All Wells: Submit this Conn within 30 days of completion of well
construction to the following:
^.Static water level below top of casing:- 20 Division
Ct.
��.�a+er feud is above cashrg,use sion of Water Resources,II1ItilTnatio❑Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 6 (in.) 1
24b.For Infection Wells: in addition to sending the form to the address in 24a
Well construction method: 20-It, r 1 above,also submit one copy of this form within 30 days of completion of well
auger,rotary,cable,direct push,etc.) construction to the following:
'?fit WATER SUPPLY WELLS ONLY: o e Division of Water Resources,Underground Injection Control Program,
S 1636 Mail Service Center,Raleigb,NC 27699.1636
Yield(gpm) Method of test: Blow 24c.For Water Supply&Iniection Wells: In addition to sending the torn to
HTH 1 lb. the address(es) above, also submit one cppy of this.form within 30 days of
1?.Disinfection type: Amount: completion of well construction to the countyf health department of the county
where constructed. I
nn li`w-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22.2016
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