GW1-2021-02239_Well Construction - GW1_20210722

='YELL CONSTRUCTION RECORD.(GW-Il For Internal Use Orly:
Well Contractor Information:
Grant Mason 19:WATE.20N '',;
Contractor Name _ FROM TO DESCRIPTIO
4254A qgofL ys ft.
ft. fit.
N.W. Poole Well & PumpCo. FAOA1t[TES-GTOSING.foFmDlAhiEIERe� THICKNESS Well-Contractor Certification Number
ESS MATERIAL
+� rL ft. g In. 188 gals.
..ompany Name
16 INNER.CASII G..0AT.UBINM ."' g6iW:16661
Well Construction Pernlit N: FROM TO DIAMETER THICKNESS I MATERIAL
'A/all applicable ivell conso uction permits(i.e.U1C,County.Slat,Variance,etc.) ft. ft. In.
�'dell Use(check well use): ft. ft. In.
-dater Supply Well: `;1't:SCREEN:- _�, ;;: ,..:. ,:.. ..
--- FROM TO DIAMETER.I SLOT SIZE THICKNESS I MATERIAL
;Agricultural E)Municipal/Public H, fL in.
^Geothermal(Heating/Cooling Supply) XDResidential Water Supply(single) R. ft. In.
JIndustrial/Commercial D Residential Water Supply(shared) 18,GIRD
.U:'T::: -
_r)Irrrzi alion FROM TO MATERIAL EDIPLA7.EMENT METHOD&AMOUNT
24on-Water Supply Well: fL ft.
;_:Monitoring Recove
rY fL ft.
srjection Well:
rhAquifer Recharge Groundwater Remediation ft. ft.
.19 SANDIGRUVEI °ACK ifa""Ilceble
�.quifer Storage and Recovery Salinity Barrier FROM TO I MATERIALI EMPLACEMENT h1EIHOD
(!Aquifer Test OStormwater Drainage fL ft.
�1Experimental Technology DSubsidence Control fL ft.
Geothermal(Closed Loop) 13Tracer 30i;I)RILLINGLOG itticFiiiddltiotral.§heetflfltecessa';
_'.Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
FROM TO DESCRH'TION(color hardness,solllroek min sin etc.
U fft. 2 ft.
s.Date Well(s)Completed: —.22- Z f Well IDN lJIf
fL fL f t
;;.Well Location: / fL !�5 fL r�� V
ft. J ft.
/-.cilitydOsvner Name f J Facility IDN(i applic�able) ft. ft. L
5 re pl 202�
F In4�rrf ari r Messing Unit
'h}sical Address,City,and Zip SO ft. ft.
�1R See �n
Parcel Identification No.(PIN) I Used hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ell field,one latlong is sufficient)
3 k-0 J g U�7 J 55� 1 22.Certification:
Aare)the vvell(s)Ex Permanent or OTernporary Signature of Certified Well Contra for Date
0y signing this form,I hereby cert yy that the ivelgs)was(were)constructed in accordance
€s this a repair to an existing well: [D Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
f this is a repair,fill nut krtoivn well construction information and explain the nature of fine copy of this record has been provided to t/ne well owner.
o:nair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
w'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
onstruc(1on,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
frilled:
SUBMITTAL INSTRUCTIONS
Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
nudtiple wells list all depths iJdereiu(example-3@200'and 1@!00') construction to the following:
Z �Static water level below lop of casing:
" (ft.) Division of Water Resources,Information Processing Unit,
.rarer level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
:.Borehole diameter: 6 (in.)
24b.For Iniection Wells: in addition to sending the form to the address in 24a
Well construction method: 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: j
^OR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
^'•Yield(gpnr) Method of test: Blow 24c.For Water SunDiv&Injection Wells: in addition to sending the form to
HTH 1 lb. the address(el) above, also submit one Opy of this form within 30 days of
i.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016