GW1-2021-07326_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Kevin Letchworth 14.WATERZONEB,
Well Contractor Name FROM TO DESCRIPTION
2514A rt. rt.
rr. rr.
NC Well Contractor Certification Number (W
15i"OUTER;CASING:116Ir l- eas' lle OR LINER"if:i''livable"-�...
N.W. Poole Well & Pump Co. FROat TO DIAMETERI THICKNESS MATERIAL
+•' ft. 0 ft. / In /u
Company Name 1� od
Q 16ANNER:CASINIG-OR TUBING: cottiermiliclosed loo
2.Well Construction Permit#: 7i d✓ ^ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction perm6s 0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
# 17,SCREEN
Water Supply Well:
' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agicultural ❑Municipal/Public tt. ft.
❑Geothermal(Heating/Cooling Supply) ^esidential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Wells>100 000 GPD FR MROUT. To . MATERIAL
❑Irri Irrigation EMPLACEMENT MET'HOD&MtOUNT
1 Non-Water Supply Well: D it. W ft.
❑Monitoring ❑Recovery tr. tr. ~ 1XN
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier L19.SAND/GRAVEPACK`ife' l ksble
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fr. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ;201'DRiBLING3OG atticFiidditionil'shoebifri"e'ceSs
t❑Geothermal Heating/Cooling Retum ❑Other ex lain under#21 Remarks FROM To DESCRIPTION color,hardnen soillrock e gain e etc.)rr 0 tr. Z,t tr. SO.
"•.Date Wells)Completed:S IT Well ID# I ft. ft. s i 1 S
Sa.Well Location: tr. rr fr.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
014 5 ,o 1?D /a,�t, N� ft. ft.
Physical Address,City,and Zip V ft. ft.
m418?10 SAO 21:REMARKS
-ounty Parcel Identification No.(PIN) Used hardened steel drive shoe
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat4ong is sufficient) Dr 22.Certification:
3so 3�Y7�.� _N �b�Ib'Itst�O /, W � /
;i.Is(are)the well(s):•A*ermanent or ❑Temporary Signature of Certified Well Contractor Draft f
By signing this form,I hereby certify that the well(s)ivas(were)constructed in accordance with
Is this a repair to an existing well: ❑Yes or ).YNO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
;Fthis is a repair,fit!out known a ell construction information cord explain the nature ojlhe of this record has been provided to the well owner.
.pair under#21 remarks section or on the back ojthis form
23.Site diagram or additional well details:
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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
p 0 24.SUBMITTAL INSTRUCTIONS
: Total well depth below land surface: �0 ft
1=or•multiple wells list all depths ifdifjerent(example-3@200'and 2@100) ( ) Submit this GW-1 within 30 days Orwell completion per the following:
M.Static water level below top of casing:_ Z d (ft) 24a. For All Wells: Original form to Division of Water Resources (DR),
1`ivoter level is above casing,use"+ WInformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
31.Borehole diameter: I f (in.) 24b.For Iniection Wells: Copy to DWR Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC 27699-1636
k2.Well construction method: Ltd\/
i;.e.auger,rotary,cable,direct push,etc.) 24e.For Water Siupel and O en-Loo :Geothermal Return Wells:Copy to the
county environmental ea th epartment o e county ere costa led
i FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producina over
to DWR,CCPCUA
�3s.Yield(gpm) 2S Method of test: O W Permit Progam,1611 MSC,R v J r99
13b.Disinfection type: Amount: 0CT 0 6 2021
I
Fonn GW-1 North Carolina >� afa�lat6{processing Unit
Department of Environmental Quality-Division of Water Revised 6-6-2018
DWR Se'f"