GW1-2021-07130_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 2j
Kevin Letchworth ® 514.'WATER-ZONES
21
... - _
Well Contractor Name 7pi
DESCRIPTION
2514A , %2 it �
NC Well Contractor Cer�tiAfication Number Co. �1�.` ���
N.W. Poole Well & Bump C �rc)ceVs`n�� PROMUTER CAS (for, MME ERtizeased e� OTHICKyNEpSS a jbihMAtERL1L
n Z ft. V ft /y n in. 'Jet /✓
Company Name ,(i D
16t•INNER;CASING:OR TUBING eothermal:closed-too ',',.
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN i .
FROM TO DIAMETER I SLOT SIZE I THICKNESS •MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) AkeSidential Water Supply(single) 8• ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ;18r GROUT
❑Irrl ation ❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: toft. W ft.
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑ "19.SAND/GRAVEL PACKifs licibleSalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ,20DRILLING LOG itticti additionit'sheets`if necess
❑Geothermal(Heating/Cooling Coolin Re FROM' TO DESCRIPTION color,hardness soutrock rain size etc.
( g/ g ) ❑Other(explain under#21 Remarks) ft. it.
<<
4.Date Well(s)Completed: 2� Well ID# t ft. ? ft.
Sa.Well Location:
Z ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
/y°W ft. ft.
Physical ddress,City,and Zip ft ft
hza�r 21'REMARx5
County Parcel Identification No.(PIN) Used hardened steel drive shoe
t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lonngis sufficient) 22.Certification:( g
�f7 l()l aC N J7 3t W
6.Is(are)the wen(s): �&ermanent or ❑Temporary
Signature of Cerrified Well Contractor Date
By signing this form,I hereby certify that the;well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Ago 15A NCAC 02C.0100 or 1 SA NCAC 01C.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 ofthis farm 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /'<P� (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft�iO .
If water level is above casing,use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:
r 24b.For Iniection Wells:Copy to DWI?,Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ,-J,?1"' 24c.For Water Su I and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.)
county environments a departmerit o e county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 I
13a.Yield(gpm) Z Method of test: a �
13b.Disinfection type: � q Amount: /4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018