GW1-2021-07131_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: � -n d��
��l
Kevin Letchworth i
e�9 14._-WATER ZONES ,..
Well Contractor Name Q FROM TO DESCRIPTION
2514A 6 1�9 q6w 5*0 ft. S9 ft.
NC Well Contractor Certification Number �1 Q '��n
i�(\ 0��0 '=15.OUTER;CASING.for_multi-cased.wells`.OR LINER if applicable)'-
N.W. Poole Well & Pump CQ�{0((�:�n`^'�Se FROM TO DIAMETER THICriT7ES5 MATERIAL
l V`�
Company Name ft. ! Y. in. lie /V
/''�!r � :16i INNER CASING.OR':TI7BING"'eothbrmal'elosed loo
2.Well Construction Permit FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) f, ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 17aSCREEN"
FROM TO DIAMETER SLOT SIZE K THICNESS ..MATERIAL"
❑Agricultural ❑Municipal/Public fr. ft. in.
❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) :18;GROUT -
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT..
Non-Water Supply Well: ft. ?O ft. 7 ,.
❑Monitoring ❑Recove
rY ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salini Barrier 49:1SAND/GRAVEL PACK:ifa. lieable
q g ry tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20'DRILLINGTOG attachadditio`ri shiets itnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc..
Q ft. /C ft.
4.Date Well(s)Completed: Z� Well ID# ft. � ft.
5a.Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3oz .�z y -'J eC:ry �:/Y C� � / ft. ft.
Physical Address,Ci ,and Zip ft. ft.
/ //�j 23e'REMARKS
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or ❑Temporary Signature of Certified Well Contractor Date(
By signing this form,I hereby cert fy that the well(s)(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANO 15ANCAC 01C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SOS' ft.)
For multiple wells list all depths ifdi/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: (ft.)
ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: lL7 (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.)
24c.For Water Su 1 and O en-LoopGeothermal Return Wells:Copy to the
county environmenta a epartment o e county where installs
FOR WATER SUPPLY WELLS ONLY: j
24d.For Water Wells producing over 100,000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, �'
am,1611 MSC,Ralei NC 27699-1611
`� �`/"�`+�'
13b.Disinfection type: si kl- 'F/Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018