GW1-2021-00796_Well Construction - GW1_20210303

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronnie Stancil
Well Contractor Name FROM TO DESCRIPTION
2283-A �:> , o oQ 1
�O� ft. ft.
NC Well Contractor Certification Number
`tl�rN�� 35r I G for,iuultl<cswells pR= TPvR" Sri'
Grady Poole Well & Pump Co., Inc. - FROM TO DIAMETER THICKNESS MATERIAL
0 ft ft. 6 f m. U e
Company Name ,^` 4G;3IVPl CaXS G=L1R913111NSi` tllcrarettlliseddoo -< .�. .'
2.Well Construction Permit#: GW-027947-20194 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft 1 in.
3.Well Use(check well use): f}}t.*' ft, to
Water Supply Well: FROM TO DIAMETER: BLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft, im
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft.
❑lndustriaVCommercial MResidential Water Supply(shared) t11 GR - .,
❑Irri ation ❑Wells>100,000 GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Bentonite Gravity
❑Monitoring ORecovery ft. ft-
Injection Well:
IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
k9. Al+lif7f.G '1rEL:P fttliilte ;
OAquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft, ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer Gt ,tittaeidit►anat b = $ ` '_
❑Geothermal Heatin Cooling Return) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color,saran aoiVrock a size etc.))
ft. 2_ ft. Topsoil
4.Date Well(s)Completed: 3/23 121 Well 1D# 2 ft' ft'
5a.Well Location: 94' ft' �® ft' if C
WoodyBuilt LLC ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. %
2645 Winter Storm Rd. Zebulon 27597 ft. ft.
Physical Address,City,and Zip ft. ft.
Wake 2706477932 z
z
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification:
N W
6.Is(are)the well(s): nPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled'o^e 0 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ff} Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
2(� 24a. For All Wells: Original forth to Division of.Water Resources (DWR),
10.Static water level below top of casing: (ft.
ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy toIDWR Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: BIoW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 Lb.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources F Revised 6-6-2018
i