GW1-2021-07454_Well Construction - GW1_20211006

°V.NELL CONSTRUCTION RECORD (GW-1.) For Internal Use Only: ,F
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...q°Jell Contractor Information:
'rant Mason
b1SATE.'r7.0N „ -
:'.ell Contractor Name FROM i0 DESCAIP770N S.
?254A `��` ft. ft.
fL .fL
Well'Contractor Certification Number �O �CJ r
�`,R.1N. Poole Well & Pump Co. \�fi�t ' �� >sr.0i1TA5iNG'foEmaltlFeaedwells;ORLINER(it.3""lieabliP­
ERXQ FRb TO DIAMETER THICKNESS MATon,panyName `� 1023n. in. .1gg galp� 16INNER.CASINO..OR;2'UB1NG therriial:elased=ltio"
:=.Well Construction Permit d:�w-0 Y 7l fl /-7��Z0 FROM I TO I DIAMETER THICKNESS I MATERIAL
;.isr all applicable well construction permits(i.e.U1C.Counq;,Stale,Variance,etc.) ft ft. In.
i�Jell Use(check well use): fL ft. in.
Water Supply Well: =`11 SCREEN:::
FROM 70 DIAMETER TS ZETIIICKNESS MATERIAL;Agricultural Municipal/Public ry, ft. in.
SGeothermal(Heating/Cooling Supply) X'MResidential Water Supply(Single) g, fL in.
Industrial/Commercial DResiderilial Water Supply(shared) YB GROUT s::
_)Irrl atl0n FAOM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
�I'Monitoring URecovery fL ft.
Injection Well:
ft. ft.rAquifer Recharge Groundwater Remediation
,Aquifer Storage and Recovery Salini Barrier 19'$ANl)IGRAVEI1'ACI{ ifa 'llc`eble
h' FROM TO MATERIAL I EMPLACEMENT METHOD
_;Aquifer Test E)StormwaterDrainage ft. ft.
oExperimental Technology OSubsidence Control ft. ft.
9Geothennal(Closed Loop) OTracer O:DRI LINGLOG:st6ch iddliloiisish€eti'Ifileee�sa
7IGe'othermal(Heating/Cooling Return) nOther(explain under#21 Remarks FROM TO DESCRIPTIOQN(coloCr'hardness soll/r«k ralnSim etc.
ft. �7 CL F J o r/
✓ate Well(s)Completed: Well ID# Z ft ft,
Well Location: / fL a cr ft. ,
U'I t f /S I iC/).ta2s�
ft ft.
7:cilioy/0wner Name Facility IDN(if applicable) ft. ft.
3 S 2 Z ed v(-On 12� Z e fl. ft.
=h%sical Address,City,and Zip ft. ft.
nnt`F',V Parcel Identification No.(PIN) Used hardened steel drive shoe
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
field,one lat/long is sufficient) Q�
5. �a N t/,31010 W 22•Certification:
c>.�
.-s(are)the s+'eil(s)EIPermaneut or OTemporary Signature of Certified Well Contra for Date
I
0y signing this form,l hereby certo that the well(s)was(were)constructed in accordance
as this a repair to an existing well: .QYes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
,this is a repair,fill out Anowrr well construction igformation and explain the nature of the cop)'of this record has been provided to the well owner.
.,pnh under#21 remarks section or on the back of Unis 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
"onstntc on,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
:Trilled:
S $UBMITTALINSTRUCTIONS
Total well depth below sand surface: (ft•)nur/tiple wells List all depths 1f dWereiu(e.rample-3@100'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
2-0 constructionto the following:
r•Static water level below top of casing:_ (ft.) Division of Water Resources,7 n•ater lonel is above casing,use"+^ Information Processing Unit,
1611 Mail Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 6 (in.) I'
24b.For Iniection Wells: In addition to sending the form to the address in 24a
?. *Well construction method: ReH/ V above, also submit one copy of this formwrithin 30 days of completion of well
.e.auger,rotary,cable,direct push,'etc.) construction to the following: I
M
"1h WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
Yield(gPm) Method of test BIOW 24c.For Water Subaly&Iniection Wells;' In addition to sending the form to
Ib.' the address(eS) above, also submit one cppy!of this.form within 30 days of
_`?b.Disinfection type: HTH Amount: completion of well construction to the coudtyihealth,department of the county
where constructed.
s I
ca�nvt1--1 •. North Carolina Department of Environmental Quality-Division of Water Resources
i Revised 2-22-2016
I. , •