GW1-2021-07441_Well Construction - GW1_20211006

rvaKe. county Well Repair Report / Wellhead Inspection r q est s
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Wake County Well Repair permit#
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�1 010����' Owner;
Site address; �v l
Ca•rn
QW`� Owner contact phone number i G r
City; ZIP Code:
2_7 IoG6
77sPection?
„ Well tag located? y
�p 01 1
Casing depth:
Water zones: WWII yield:Existing liner or screen? I
S Well depth:
N o ZOo
Evidence of original grout: Total depth of liner or screen:
/� c- Wellhead above grade?
Y-e1
elf d("sCct,o +t"ur\ CiT�-e,• ��h a h e�v ��riint�,�L
GISC) kar. A— q64 +lie+-e
Cpl. b•rcc<<h C
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Cow.; IJ
Well depth; 6 G
Well yield: 7
Water zones ; �"'
133— I3q.�.} stat►c'level: �3
Water zones:
Liner installed? Yt5 Liner depth from top of casing:I Ito t+
Screen Installed? N •
Depths of screened sections?
Well hydro fractured? No
Wellhead raised above grade? N o
Pic I;'-eA— boo+ at+ �I�P+
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wrtfCl Zovws 01 aTi,.q�-oG�
Contractor Nsmey
NCWCCC Certification number:
� 14
5 2
$Ignature of contractor: Q Date: 7 7-1
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Contractor phony number: 3 3 y
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Wake County well repair report?/09ver,,

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
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1.Well Contractor Information:
Kevin Letchworth
14`:WATER ZONES
Well Contractor Name O ` ,6\ FROM TO DESCRIPTION
2514A �,� �5`��V S- ft. ft. �.
/S a
�� S 15.AUTER CASING for multi-cased)
e
Iee�'o�
NC Well Contractor Certification Number :wells OR°LINER'if a_)'cable
N.W. Poole Well & Pump Co��so\l 1�Nt� FROM TO DIAMETER THIiCpKNpESS MATERIAL
Company Name
13
ft.
t 3� ft. 4y in. !0 O J
['�\.(f` 16:-INNER CASING OR T[JBING eother`mal closed-loo .
2.Well Construction Permit#: ` V �O I FROM TO DIAMETER THICKNESS MATERIAL`
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): tt. ft. in.
17'SCREEN''
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural �Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT'
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 39 r ft. �7EnrL
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
lq
❑Aquifer Storage and Recovery ❑Salinity Barrier "FROMAND/GRTOVEL'PACK MATERIAbL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG'attach additional.sheets:ifaecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock rain size etc.
rV ft. Z3, ft. C
4.Date Well(s)Completed: Well ID# Z3'ft. 3D ft. c Si r1
5a.AVell Location- ft. ft. f, �C
ic vl ft. ft/�
Facility/Owner Name g^`, Facility ID#(if applicable) ft. ft.
2 ft. ft.
Physical Address,City,and Zip ft. ft.
;'21:REMARKS <
County r f Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) QQ ��f^� t 22.C rtif lion:
6.Is(are)the well(s): ivermanent or ❑Temporary Signature of Certified WellLontract-Cr�; Da e
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: ❑Yes or )ONO 15A NCAC 01C.0100 or 15A 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 ofthis 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 details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page td provide additional well construction info
construction,only I 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!
9.Total well depth below land surface: ` (ft.)
For multiple wells list all depths ifdierent(example-3 a200'and 1@100�For this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:
,3o ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+^ (ft)
Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:_ (� rr (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: alr w r
24c.For Water Supply and Open-Loop'Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department or the county where ms ed
FOR WATER SUPPLY WELLS ONLY: Copy CCPCUA
24d.For Water Wells producing over 100,000 GPD: Co to DWR
��13a.Yield(gpm) hod h1c,w Permit Program,1611 MSC,Raleigh,NC 27699-1611
Method
of test:
13b.Disinfection type: rA Amount: /11�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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