GW1-2021-07174_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: '7
Kevin Letchworth
Well Contractor Name FROM TO DESCRIPTION
2514A a ft
NC Well Contractor Certification Number
15.'OUTEXCASING'(f6i.j itulti-rAKAvellss TO LINER.0faii licable)---�
N.W. Poole Well & Pump Co. FROM TO DIAMETER - SS' MATERIAL
ft. J07 ft. r in. 1,Sd J(C)
Company Name
16.INNER CASING OR ING'(66theirmalclosed400p)
2.Well Construction Permit#: N6 FROM TO DIAMETER f THICKNESS _T MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
.
Water Supply Well: 117 SCREEN,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural )&unicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) —f t. ft. in
Olndustriai/Commercial OResidential Water Supply(shared) —,18s
GROUT,
OIrrigation oWells>100,000 GPD FROM TO 'MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f, loo ft
DMonitoring ORecovery ft ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation '19:;SAND/GRAVEU'.PACX if iblifleib le).
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test 13Stormwater Drainage ft. ft.
OExperimental Technology oSubsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,sollfrock type,grain s etc.)
0 't. ft. CJ*!k-1;
4.Date Well(s)Completed:Sale Well ID# If ft. 9.9 ft.
PO F Otw,47,
5a.Well Location: ft. 61W ft.
gadi-
17M ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
t�d
Physical Address,City,Wd Zip ft. ft.
hu 14 31 REMARKS, 1-01
County Parcel Identification No.(PIN) Used harden6d steel drive shN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification:
3T-0?5' 13 8 1 N —9f, za��� 0
6.Is(are)the well(s): *fermanent 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: OYes or ANO 15A NCAC 02C.0100 or 15A NC,4C 02C 10200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form i
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 I 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: 0001 (ft.) ys g
Submit this GW-I within 30 da of well completion per the followin :
For multiple wells list all depths iftlifferetif(example-3@200'and 2@100�
10.Static water level below top of casing: 30 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+., Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
It
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Sup Open-L!oop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) sr county environmentalykv department of the county where in—s=e
FOR WATER SUPPLY WELLS ONLY:
24d.For Water eLl1hrCil g over 100.000 GP):Copy to DWR,CCPCUA
— Wells ,a r
Permit Program,16 Raleigh; 6_1?
13a.Yield(gpm) 5— Method of test: O
HT
13b.Disinfection type: P(Amount: '4
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018