GW1-2021-07459_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(CW-11 For Internal Use Only:
1.Well Contractor Information: ' I
Kevin Letchworth 17
1 TE ZONES
Well Contractor Name OM TO •DESCRIPTION
2514A I W—K
pC� & ft.
NC Well Contractor Certification Number
M'OUTER CASING(foe Xsed R LINER flfiui licabli)
To THICKNESS MATERIAL
FROM DIAMETER N.W. Poole Well & Pump Co. �ql Ew. T TH, S
I'S ft. & 44
Company Name
IRMNNWER SING:OR TUBING-(geothiritiall cloed-limp)
7911
2.Well Construction F ermit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction per itsUIC,County,State,Variance,etc.) ft. ft. im
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17.SCREEN,
FROM TO I DIAMETER I SLOT R177, I TH1('WNF_q4Q I MATERIAL
OAgricultural OMunicipaUPublic ft. ft. in.
OGeothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft. in.
DlndustriaUCommercial OResidential Water Supply(shared) is.GROUT
.-
OTigation DWells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ZO ft' bbf,-V'7?� Pa W
DMonitoring ORecovery ft. ft.
Injection Well:
ft. ft.
OAquifer Recharge ElGroundwater Remediation
SAND/GRAVE 'PACK ffappliiable)
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT. I METHOD
[]Aquifer Test CStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 10.--DRILLING.LOG(attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) FROM TO DESCRNTION(color,hardnev,soul ck type,grain size,etc.)
32- ft. -- A,4'1�
51 t 4,44
4.Date Well(s)Completed: Well ID# ft. I
A1*rW "14�
5a Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
qIX %UJv&( LA1411 At e77j-?/ ft ft.
C
Physical Address,City,and Zip ft. ft.
[Ake q 04�J(0 q j �1L RENIARKS,,.!!,,,�,w_,,
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
3s"�ajc \ N _ W
6.Is(arc)the well(s): Oermanent or OTemporary Signature of Certified Well Contractor Date I I
By signing this form,I hereby certify that the well was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or Po JJA NCAC 02C.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 1121 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled:
rq 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IpQJ —00 For multiple wells list all depths Submit this GW-1 within 30 days of well completion per the following:
ifdifferent(example-3@200.'and 2@100) 1
1 24a. For All Wells: Original form to Division of Water Resources (DAIR),
10.Static water level below top of casing: (ft
Ifivater level is above casing,use"+" .) Information Processing Unit,1617 MSC.,Raleigh,NC 27699-1617
11.Borehole diameter: t (in.) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 0_t/
- f I 24c.For Water Su y and Open-Loolp Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) I county environments11health department I of the county where i—n—sta7v
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over,100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:_6fk�%A�r kT4 Amount: 2,W
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018