GW1-2021-07132_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ,SN E-0
Kevin Letchworth pr
14.WATER'ZONE&J"'t­_
Well Contractor Name FROM TO DESCRIPTION
2514A
TWO ft. ft. /cv Zqs ly
NC Well Contractor Certification Number ft. I 2,0-5-ft. Of
Co %nj()tM3t10 �t Se6oln ;,,'15.>OUTER'CASING`(foi-fiiulti-ci kkdiwells)OR LINER`(if.ii)ti Liable
)�'.-,-�"�,*,, I I I
N.W. Poole Well & Pump ONN FROM I TO I DIAMETER , THICKNESS MATERIAL
ft. I ft. I
Company Name q0
.'16ANNERCASINGOR TUBING(06thermal closed 400p) f
2.Well Construction Permit FROM To DIAMETER 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.
,11 SCREEN:.
Water Supply Well: -FROM TO DIAMETER,I METER SLOT SIZE THICKNESS MAT,ERIA
CAgricultural oMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. .ft. in.
/A
0 hidustrial/Commercial OResidential Water Supply(shared) g.r,ROUT-
DIrrigation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft L0 f" k,-'hA ifT 601,r
DMonitoring DRecovery ft ft. r
Injection Well: ft. ft.
OAquifer Recharge DGroundwater Remediation r.19.'SAND/GRAV EL,PACK(if ipplicabli)
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test OStormwater Drainage ft. ft
OExperimental Technology oSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer ',20;;DRIL-LING'L0G*(attach additional sheets if iieccssiury)'.,
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 FROM Z)M To DESCRIPTION
- DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
ft. o e ft )
.
—t^, 0-N- r I
ZL
4.Date Well(s)Completed: Well ID# ft 1 0 I ft.
5a.Well Location: ft. ft.
62 "r gme_5 ft. ft.
/Facilil�/Owner Name Facili ID#(if applicable)) ft. ft.
-5301 ./ &6 ft. ft.
Z12A
Physical ddress,City,and Zip ft. ft.
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/Iong is sufficient) 22.Certification:
0 N W
6.Is(are)the well(s): e rmanent or OTemporary Signature of Certified 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: E]Yes or *0 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:
1
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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Youimay also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 26f 1
—(ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100)
10.Static water level below top of casing: go (ft) 24a. For All Wells: Original fonn'to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) Program,
For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
t Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: av
24c.For Water S � d Open-Loop Geothermal Return Wells:Copy to the
direct push,etc.) county environmeu e'y
(i.e.auger,rotary,cable,d R ffa tF department of the county where installed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 2_ Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: k 4' 617 Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018