GW1-2021-02247_Well Construction - GW1_20210722

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HELL CONSTRUCTION RECORD(GW-11 .. For Internal User
r r / JCk'*'dell Contractor Information: . . •
r
Grant Mason 19c'WATE
"eII Contractor Name FROM TO DESCRIPTION
160 ft e) ft.
?254A
ft ft {
?:'tVetl'Connactor Certification Number I&QUTER CASING;for':iiifilil-laa¢d:wells Yi11�1iINER-1La Ur6ble..::
+•l.iN. Poole Well & Pump Co. FROM TO DIAMETER I THICKNESS MATERIAL
+ rt ft. 6 In. 188 gale
ongrany Name
&2 7 c/�r/ 16.JNNER:Ci1SING`OR;.TUISIlVG;' "th`efiNei elosed lbo
Weil Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
all opplicable+velt construction permits(i.e.U1C.Count),,State,Variance,etc.) fi. ft. In,
ft. rt. In.
Well Use(check welt Ilse):
Ili SCREEN „, '
Water SllPPI}Well: r. -: _.
FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
'Agricultural ft. fl in.
iGeothennal(Heating/Cooling Supply) Residential Water Supply(single) H.
ft In.
_,.
thtdustrial/Commercial Residential Water Supply(shared) 38i GROUT
__ Irrl orlon FROM TO I MATERIAL EMPLACE NT METHOD&AMOUNT
1-lon-Water Supply Well: 0 rt. 2 ft. G
JIVIonitoring Recovery ft. ft. r
To
Jection Well: fa ft.
tAquifer Recharge Groundwater Remediation
'"' .1�:t5AND(GRAYELPACKlta"'llciible _ -
—;Aquifer Storage and Recovery Salinity Battier FROM TO f MATERIAL I EMPLACEMENT METHOD
'Aquifer Test OStormwater Drainage ft ft.
.JExperimental Technology Subsidence Control ft. ft.
DGeothennal(Closed Loop) OTracer ti!;>iRILLlNG LbG:atlii'th_6ddlttbiiat;'stieei3;lt,i4e@easa
FROM TO DESCRIPTION(color,hardness,sollImIt type,Xmin slu etc.
'Geothermal(Hearin Cooling Return)' [Jolliet(explain under#21 Remarks tt 2 ft. To I I
r
Date Well(s)Completed-3 �Z�Well ID# ft. iz. <1.
fL m `tom'
<:.Nell Location: -
01 ft ft,
cilinl0��•ner Name Facility ID#(if applicable) tL ft.
2 r �� e rn•c r�1� G n rru.z 1Cli���,��� ft. £t.
r;sical Address,City,and Zip a �,SaS ft ft (OZ'�.�fJSA
C'/J or
t.: Parcel Identification No.(PIN) Used hardened steel drive shoe.
.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
+ell field,one[atllong is sufficient) 22.Certification:
stare}rite+veil(s) Permanent or Temporary Signature of Certified WellContr� ;, Date
By signing this form,1 hereby certiry that the well(s)was(were)constructed in accordance
this a repair to an existing well: E3Yes or �X. No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constrtclion Standards and that a
tIbis is a repair,fill out knomn well construction information and explain the nature of the copy of this record has been provided to the welt owner.
;pair under 821 rentarkt section or on the back of this form.
23.Site diagram or additional well details,
F-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
-cnsutic on,only I GW-I is needed. Indicate TOTAL.NUMBER of wells construction details. You may also attach additional pages if necessary.
itilled: ! SUBMITTAL INSTRUCTIONS
G
Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well^a nndt(ple wells list all depths if dti ferew(erample-3@200''aand 2@100') construction to the following:
at.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
haler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
?.Borehole diameter: (in.) 24b.For Iniection 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
'Nell construction method: �1/tf construction to the following: '
e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
�{ Blow i'
Yield(gpm) i Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the fonn to
the address(es) above, also submit one cppy of this!.form within 30 days of
i..Disinfection type: ITN Amount: 1 lb. completion of well construction to the county health department of the county
— where constructed.
^nu G%V-I •.'North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016