GW1-2021-07328_Well Construction - GW1_20211006

WELL CONSTRUCTION_RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Kevin Letchworth ®�9
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2514A 6 �01 ft. ft. Z
QC ss�r9 ft. ft.
NC Well Contractor Certification Number �pCOC'e' C(1 15.:OUTER,CASING for_Wti-cased.well� OR LINER Ifa llcable :,:.
N.W. Poole Well & Pump Co. , �'���3` NR�eG FROM TO DIAMETER ! THICKNESS MATERIAL
G, �t-� ft. fr. in.
Company Name r ,*
// -♦j r.161NNER.CAS OR TUBING eothirmal`elo�ed loo {
ia.Well Construction Permit#: f �"4� ��`� r 4740� FROM TO DIAMETER I I THICKNESS I MATERIAL.
List all applicable hell construction permi s t.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic in.
❑Geothermal(Heating/Cooling Supply) kResidential Water Supply(single) ft. ft. in.
i❑industrial/Commercial ❑Residential Water Supply(shared) -
'i❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z� ft. _f
❑Monitoring ❑Recovery ft. ft.
I Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK-if a" licabli;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
s
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
'❑Geothermal(Closed Loop) ❑Tracer 30.DRILLWG LOG:atlseti'sddltioniil sheil9 tf i ece isa
❑Geothermal(Heating/Cooling turn) ❑Other(explain under#21 Remarks FROM TO DESCRIPTION color hardnaa solUrock e, rein a ere.
� ft. Z ft. J ,
Q"
4.Date Well(s)Completed: Well ID# 2 r fr. -'D ft. Ch1 • C c
i
5a.Well Locatio ft. S ft. 1 'C o
FISM J„ ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Physical Address,City,and Zip V ft. ft.
Ll J&g _,� � .J / 01I.,REMARKS
:aunty Parcel identification No.(PIN) Used hardened steel drive shoe
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufficient) 22.Certifrcati
�j,(n35�5�1a N —72L 1%70 W .z
%S 2
n.ls(are)the well(s): ❑Permanent or ❑Temporary Signature ofCemfied Well Contractor D to
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance ivith
Is this a repair to an existing well: ❑Yes or iVo 15A NCAC 02C.0/00 or/SA 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 of this record has been provided to the ivell owner.
repair under Ul 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
.Total well depth below land surface: (b G.� (ft)
For nudriple wells list all depths iifdii ferent(example-3@200'annd 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2-0 (ft) 24a. For All Wells: Original form to'Division of Water Resources (DWR),
Ifwater level is above casing,use"+"r( Information Processing Unit,1617 MSC,lRaleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699,-1636
E2.Well construction method: - Q r 24c.For Water Su 1 and O en-Loop!
n-Loa Geothermal Return Wells:Copy to the
!i.e.auger,rotary,cable,direct push,etc.) county envrrorimenP tea t department of a county ere instal ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducing over 1R000 GPD: Copy to DWR,CCPCUA
/ Permit Program,161 I MSC,Raleigh,NC 27699-1611
1..3a.Yield(gpm) / Z Method of test: // w
13b.Disinfection type: Amount: J 16
',orm GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
I