GW1-2021-02243_Well Construction - GW1_20210722

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WELL CONSTRUCTI©N RECORD(GW-1) • For Internal Use Only: C
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well Contractor Information: . . '
Grant Mason I
ICY lv
Contractor Name FROM TO DESCRIPTIO i.
t254A gofL 5 it. 2 d«t
it. St.
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:r Wetl'Conuactor Certification Number iI5cOUTER CASING::foE'Atrlfl4Abed*eIb,i11t;IiINElt lf.S Ui hhlile :' :,
f\l,W. Poole Well & Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
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_.ompanyName ,y� 4�( ft. n. g In .188 galy.
16:tNNE .CASIIVG.OR=fUNl1IG, tderrfiiil closed too'
o-'t'ell Construction Permit N: 3_J ( 1 FROM TO I DIAMETER I THICKNESS MATERIAL
.isr all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) rL f. In.
>.Well Use(check well use): rL M In.
'Water Supply jlT SCREEN Well:
F_ROM TO DIAMETER SLOTS ZE TH[CKNESS MATERIAL
,Aericultural Municipal/Public n, tL in.
,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. rL In,
Ihtdustrial/Commercial [3Residential Water Supply(shared)
Intl attOn - FROM TO MATERIAL EMPLA EMENT METHOD&AMOUNT
Hon-Water Supply Well: fL ft. j �(/ r-
Monitor ng Recovery ft. tt.
ltr.iection Well; fL ft.
r(Aquifer Recharge []Groundwater Remediation I :SANDlGRAYEY:I'ACK'iGa "Ilceble ,
ttAquifer Storage and Recovery [3Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
JAquifer Test OStotmwater Drainage fL ft.
Y ENperimenlal Technology Subsidence Control to tt.
Weothennal(Closed Loop) OTracer Zi�,fttNGILOG titiecli titldlilbnai:€lttef'(fiiecesld ;t
�rGeolhermal(Hearin Coolin Return Other ex lain under rY21 Remarks TO DESCRIPTION(ealor hardness,sallfrxk a rain size etc.slate Wells)Completed:�crc3•• Z'� Well ID#
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,;.Well Location: � J
1'�A H 13 c'
-=cility/Owner Name Facility/ID#(if applicable) fL t. rQOP�5111
G-(r,A4 m �` �t e rrc�n �cJ/ �`Juix/fit t wsdr w c ft. ft.
"h siicc'aall Address,City.and Zip s{� fL ft.
721@REIviAR11;3;:;
Parcel Identification No.(PIN) Used hardened steel drive shoe.
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
t',\ell field,one lat/long is sufficient) 22.Certification:
05ggg3 N —78 55��Q8 W J. �- 2 3-• e_r
s{are}the well(s)E% Permaneut or Temporary Signature of Certified Well C� Date
� Dy signing this form,1 hereby cert�that the,vell(s)n'as(were)constructed in accordance
i„this a repair to an existing well: nYes or L:_iNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
dri.<is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
,pair under A21 remark+section or on the hack of this form.
23.51te diagram or additional well details:
d.For 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
-onstnic on.only I GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
milled: SUBMITTAL INSTRUCTIONS
S:Total well depth below land surface: 5Q S (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
nr nudliple u:ells list all depths if dWereni(example-3@200'aand 2@100) construction to the following:
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^.Static water level below top of casing: � (ft.) Division of Water Resources,Information'Processing Unit,
7 motet/cvel is above casing,rise"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
'.1.Borehole diameter: (in.) 24b.For(nlection Wells: In addition to sending the form to the address in 24a
r r/ above,also submit one copy of this form within 30 days of completion of well
Well construction method: / construction to the following:
..e,auger,rotary.cable,direct push,etc.) _
Division of Water Resources,Underground Injection Control Program,
' Oft WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�..Yield(gpnt) Method of test: BIOW 24c•For Water Super&Injection Well Iz In addition to sending the form to
the address(eS) above, also submit one ct)'py,of this.form within 30 days of
Disinfection type: HTH Amount: 1 lb. completion of well construction to the county health department of the county
-- where constructed.
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North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-20I6