GW1-2021-07330_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-0 For Internal Use Only:
I.Well Contractor Information:
Kevin Letchworth
C NATER ZONEfi`.
Well Contractor Name FROM TOI DESCRIPTION
2514A ,��' ® c( ft. ft.
srt. ft.
NC Well Contractor Certification Number
N.W. Poole Well & Pump Co. � N 0 6 ��� &DUTEWCASING for'mulH;c wblls OltLnvER ifa"'liceble :,_-;
F M TO DLAMETE THICKNESS MATERIAL
ompany Name /n I �S ft. f� ft.
(�L(1" O�� �t l \0 A&INNER CASING OR'TUBING eothirinal`ddiied-loo
2.Well Construction Permit#: i y_ FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction pern is 0.e.UIC,Coun a c.) ft. it. in.
3.Well Use(check well use): ft. ft. in.
water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.:GROUT..:
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑Monitoring ❑Recovery tt. ft. /
I Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SANDIGRAVELFACK ifa' licable
ty FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fr.
❑Experimental Technology ❑Subsidence Control ft. tt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG:attiii h Additional sheeti if ue'cess
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color hardness,soil/rock a rz+h atze eu.
0 ft. /l tL
A.mate Well(s)Completed: 2' Well ID# '7 ft• 0 )" ft.
in,Well Loclation: ft. 2L ft. ✓ t/
ft. ft.
Fe-iili/ty/Owner Name) Facility ID#(ifapplicable) ft. ft.
/ 't� A�1 ��( 6 ft. ft.
Physical Address,City,and ft. ft.
21:
:REMARKS ,
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(lif well field,one lat/long is sufficient) 22.Certification:
*-Ware)the well(s): I zermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the weh(s)was(were)constructed in accordance with
Is this a repair to an existing well: ❑Yes or /i0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
.�;lhis 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.
,pair under#21 remarks section or on the back oft his 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-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
?.Total well depth below land surface: 2 Z (rt.)
Pcr nndliple wells list all depths ifdii erent(example-3@200'and 2@100) Submit this GW-I within 30 days of well completion per the following:
(ft)
a.0.Static water level below top of casing: 24a. For All Wells: Original form to iDivision of Water Resources (DWR),
,eater level is above casing,use"+" Information Processing Unit,1617 MSC,Ra
leigh,aleigh,NC 27699-1617
11•Borehole diameter:_ (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
L Program,1636 MSC,Raleigh,NC 27699-1636
?:<.Well construction method: (l T V
(i.e.auger,rotary,cable,direct push,etc.) 24c1 For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environments ea epartment of a county ere meta e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 0"GPD: Copy to DWR,CCPCUA
F.3a.Yield(gpm) � / Method of test: / l�ly Permtt Program,]fill MSC,Raleigh,NC 27699-1611
14
13b.Disinfection type: tr ►7 Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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