GW1-2021-07175_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: -7
Kevin Letchworth 7,
.-14.tWATER ZONES,
Well Contractor Name FROM TO DESCRIPTION
2514A g-ft. 3.16 ft.
—7— ft. ft.
NC Well Contractor Certification Number ','I 5.10UTER CASING. for.mWfi ied.,wills) LINER
H=W601liesible)�;f:
N.W. Poole Well & Pump Co. FROM DIAMETER PTI L MATERIAL
� I,.. I -
Company Name + 3 1 6 1
,11&JNNERiC.ASING.0R..TUBING
< FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: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: l7.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal(Public ft. ft. in.
OGeothennal(Heating/Cooling Supply) ECsidential Water Supply(single) ft ft. in
oIndustrial/Commercial OResidential Water Supply(shared) 19;GROUT
13hirigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a' ' 2,r) tt. �a/-e'
OMonitoring ORecovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediat'on
19.SAND/GRAvEL PACK{(ifitOOtiiable)
0Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test oStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
CGeothermal(Closed Loop) OTracer 'X DRILLINGLOG(httitth idditidnal sheets ifnecessiry)"
oGeothermal(HeatinglCooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hRrdness,soillrackriM prain size,etc.)
0 ft 2 ft- -1z e
4.Date Well(s)Completed: Well ID# 2 ft ft- C 14, y
5a.Well Location: ft. 32 5 ft-
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
30 rye e Dr. r-r,,It ft. ft.
Physical Address,City,and Zip ft. ft.
1_41 I Used hardened steel drive shoe
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
-%0\0 ' N W � 7 I-
6.Is(are)the well(s): UP4.1'a-ent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or Peo 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 I 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 G is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: !I — 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:— �C)J (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifelifferent(example-3@200'and 2@1 00�
10.Static water level below top of casing: D (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to,DWR,Underground Injection Control(IUC)
I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:. 24c.For Water S and Geothermal Return Wells:-Copy to the
county environments co
(i.e.auger,rotary,cable,direct push,etc.) effIth Pep=Re—unty where install;T
FOR WATER SUPPLY WELLS ONLY: 24d.For Water MLI%Coducing over 100,000 GPD: Copy to DWR,CCPCUA
1 11 -1611
13a.Yield(gpm) Method of test: Permit Program,161 Raleigh,NC 27699
13b.Disinfection type: Amount:
FormGW-1 North Carolina Department of Environmental Quality-Division or water Resources Revised 6-6-2018