GW1-2021-07446_Well Construction - GW1_20211006

YELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
?'✓ail ontr actor iInformmation:
y �/lr1 -lam%�`
f� r
`:`cell Contractor Name FROM TO DESCRIPTION 1. 1
(� ft. 13S rt. O Ali
a+ell'Contrauor Certification Number
N.W. Poole Well & Pump Co. \�,��c�'' ` FROM ERCASIN(>;foiltlnitlFai welli.i7R ICKNEclti6`"uiMATE,:::
Q FRbfif TO 'DIAfitETER 4THCCKNFSS AtATER1AL
ampany Name -}' fit �3 ft- 6 In. i, $$ gals.
18.ZNNE9 CASII9G::OR;.T.UBING. ' lbec'riiiil closed-ltsd"
well Construction Pernut 11: ow � �-(/� FROM TO DIAMETER THICKNESS AtATERUL
.s,all applicable well construction permit (i.e.UiC,Counlv,State.Variance,etc.) fL ft. In.
i%Jell Use(check well use): ft fit. In.
:Pater Supply Well: al1tSCREEN;.
FROhf TO DIAMETER SLOTSIZE THICKNESS MATERIAL
_JAericultural E)Municipal/Public R. ft In.
Oeothennal(Heating/Cooling Supply) iResidential Water Supply(single)
R In
Ondustriai/Commercial Residential Water Supply(shared) fit
18i GROUT
�IRI alion FAOfif TO MATERIAL I Efi1PLACEMENTMEIIIOD&AAIOUNT.
.Hon-Water Supply Well: D ft. 24 ft. % t CfrY / __ _S
r(hAonitoring E)Recovery ft fit. ` iU
t;t.jecdon Well:
ft rt
Aquifer Recharge Groundwater Remediation
F Aquifer Storage and Recovery Salini Barrier 19 SANDLGRAVEIi:PACK 1La"'llcable. ;; ;... -,..
iY FROM TO MATERIAL EMPLACEMENT
_°Aquifer TestSlormwaler Drainage fit rt.
j1Experimenlal Technology Subsidence Control fl. fit.
1Geothennal(Closed Loop) OTracer 20!;DRII LTNGLdG;'ettachai7dliloiieLaNEetAtltiteces
JGeothermal(Heating/Cooling Return Other(explain under#21 Remarks FR ft. 2� ft.OM To DESCRIPTION tcolor hardness,eolVroek type,"rain size,ere.
:fold C
Date Well(s)Complete / Well IDN I ft fie
Well Location: 9 IL fit. �J 111 Gt
ft ft.
'-.cilip•/ caner Name Facility IDN(if applicable) ft ft.
�i's ��t�� /�� fl' fl•
r sical Add r ss,City,and Zip it. fit
O7 SD55S�'
11:I1E61ARKS i i r
Parcel Identification No.(PIN) IUsed hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
s,s ell field,Pfone tat/long its sufficient) 22.Certification:
36o )`1��7 N ��e-
s(are)the well(s) x Permanent orTemporar}' Snglea wclonudcul Uate
By signing this form,1 hereby CEng that the tvell(s)was(were)constructed in accordance
a this a repair to an existing well: [D Yes or E]No with ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
<lhis is a repair,fill rna known well construction information and explain the nature of the copy of this record has been provided to the+yell owner.
:'roil wider s21 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
,• ustluc on.only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
u.�illed:
1?.
Total well depth below land surface: SUBMITTAL INSTRUCTION
D3 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
.ter nmdiiple wells list all depths if d fferent(example-3@200'and 2Q100')
construction to the following:
.'.Static seater level below top of casing:— V (ft.) Division of Water Resources,Information Processing Unit,
anal 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
a
=.Well construction method: ir (O�yy above,also submit one copy of this form within 30 days of completion of well
e.auger,rotary,cable,direct push,etc.) construction to the following:
WATER SUPPLY WELLS ONLY: o Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleighr ,NC 27699.1636
Yteld(gpm) 2 Method of test: BIOW 24c.For Water SuoDiv&Injection Wells: ;In'',addition to sending the form to
_ lb. the address(es) above, also submit one cppy of this.form within 30 days of t?.Disinfection type: FITFI Amount: completion of well construction to the county health department of the county
where constructed. ;
•. Noah Carolina Department of Environmental Quality-Division of Water Resources '
. 1 Revised 2.22-2016