GW1-2021-00203_Well Construction - GW1_20210622

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Constructon Electronic •
NorthCarolina Department of •
Di\Asion
April 1,2021
Page 1
Submission ID#
GW 1-2021-00203
CONTACT INFORMATION
..................................................................................................................................... .......................................................................... ..........
Contact Name* Email Address*
Dustin Lentchworth [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4367 A DUSTIN LETCHWORTH Upfront Well Company Of The Carolinas
2.Well Construction Permit#:
GW-046782-2020
List all applicable well construction permits(i.e.fvbnitoring Wells,UIC,County,CCPCUP,etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/22/2021 5
(gallons per minute)"

Page 2
5.Well Location
Facility/Owner Name
Trismith Construction Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Wake
Physical Address* Street Address
4721 Cypress Ford Drive
Address Line 2
City State/Pro\ince/Region
Fuquay-Varina NC
Postal/Zp Code Country
27526 us
Latitude* 35.6477420000 Longitude*-78.7854850000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
405 surface?
For multiple wells list all depths if different 73
(example-3@200'and 2@1001 in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
30 6
If water Ie\,el is abo\,e casing,use"+" in inches
12.Well construction method:
C Auger r Air Rotary r Cable Tool
C Direct Push r Mud Rotary r Rotosonic
C Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield (gpm)
5 13a. Method of test:
If applicable Blow
13b. Disinfection type:* 13b.Amount:*
HTH 1LB

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
180 181
in feet in feet
370 371 3 GPM
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 73.00 .188 Galvanized Steel
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
................
From To Material Emplacment Method &Amount
0.00 20.00 Hole Plug
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness, soil/rock type, grain size,etc.)
0.00 60.00 Sand/Clay
in feet in feet
60.00 180.00 Slate
in feet in feet
180.00 405.00 Granite
in feet in feet
21.Remarks
Used Hardened Steel Drive Shoe
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
PVSI7d LFI-CWWZIPV-
Signature of Certified Well Contractor
Submittal Date 6/22/2021