GW1-2021-02244_Well Construction - GW1_20210722

WELL CONSTRUCTION RECORD(GW-11. .. For Internal Use only:
Well Contractor Information:
Grant Mason
!14d VHATE -10 N
'!ell Contractor Name FRODt TO DESCRIPTION
4254A 120 IL I?S f. LO �P
f6 • .fL
riC.teeifcontractor Certification Number 7155,OtIT.ER{G'SING irdHhtiIll-.Wed.Welli).LlR hINER I1 Y""I►ckbl�!: :;:_, i
I.ON. Poole Well & Pump Co. FROM I To DIAMETER I THICKNESS MATERIAL
+1 fL ft. 6 in .1 g$ gals.
bnipany Name p -..
� 7 4 ;1G:i1NNER.CAS C.ORiTUB1NCr .."-'l6eriiiaiktosed lbo ";,: :_.:_ ..:.
-.:'4ell Construction Permit>Y: � +� FROM I TO DIAMETER THICKNESS I MATERIAL
`.far all applicable;yell construction permits(Le.UIC,County.State,Variance,etc.) fL n, in.
Well Use(check well use): ft. ft. In.
�;9aterSrrPply Well:
FROM TO DIAMETER SLOTS ZE I THiCKNESS MATERIAL
?Agricultural [3Municipal/Public H, ft. in.
�Geotiiennal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In..
--Ehrdustrial/Commercial Residential Water Supply(shared) 18i GROUT
Irrigation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0I
fL ?—p ft. ` �f
Jmonitoring Recovery ft. ft.
injection weli:
_ ft. [L
Aquifer Recharge Groundwater Remediation
_ 19iSAND(GRAYEh:PAC�K:1ta`'Ucable ,t,.. ;
i'Aquifer Storage and Recovery �$ahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_:Aquifer Test DStormwater Drainage ft. ft.
JoExperimenlal Technology OSubsidence Control fL ft. j
OGeothennal(Closed Loop) OTracer 26.1V ILLINGLOG attach pdditlilrial:SHaeta'lfiieeetsu
Geothermal(Heating/Cooling Coolin Return} Other(explain under#21 Remarks FROM TO DESCRiPTTON(color hardnass,soll/mck rain siu ctc.
ft ft- ii:g,:e
:.Date Well(s)Completed:-c2 Cf 2 t well ID# ft. ft.
Well Location:
-TC G- /7gme.� rL n. -�
citity/(honer Name Facility IDN(if applicable) ft. ft. J n Un�L
I L r !t' f r� C'VsA
t 3fq chef Y1elOn Dr WaX_(;fea J /t/t! of ��? ft. [R. �t VCr
!%!Ivsical Address,City,and Zip ft. ft.
2I�R>iMARK5::4',r
Parcel Identification No.(PIN) Use hardened Steel drive Shoe
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
.eell field,one tat/lcozngs sufficient) —7 / 22.Certification:
s(are}the tcell(s)EIPermaneut or Temporary SignatureofCertified W ell Cantra r Date
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance
=.s this a repair to an existing well: Yes or �X No nvith 15A NCAC 02C.0)00 or 15A NCAC 02C.0200 Well Construction Standards and that a
t r;,is is a repair,fill out known well construction hrforination and explain the nature of the copy of this record has been provided to the well owner.
.pair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
Jor 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
rust uc on,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
led: SUBMITTAL INSTRUCTIONS
/
S.Total well depth below land surface: f r�S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
..1;nurhiple wells list all depths if different(ecanhple-3@200'and 1@100')- g.
construction to the following:
'.Static water level below top of casing: ao (ft-) Division of Water Resources,Information'Processing Unit,
aier level is above casing,,use••+" 1617 Mail Service Center,Raleigh,NC 27699-1617
t.Borehole diameter: (in.) 24b.For lniection Wells: In addition to sending the„form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
Well construction method: i.t Y construction to the following:
i.e.auger,rotary,cable,direct push,'etc.)
Division of Water Resources,Underground Injection Control Program,
)st WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
.Yield(gpm) 20 Method of test: glow 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(eS) above, also submit one copy of this.form within 30 days of
Disinfection type: HTH Amount: ( Ib' completion of well construction to the county lhealI i.department of the county
-- where constructed.
Revised 2.22-2016;n;i G`d 1 North Carolina Department of Envirorunental Quality-Division of Water Resources i