GW1-2021-07460_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Kevin Letchworth �*
J:4,,WATERZONES",
Well Contractor Name FROM TO DESCRIPTION -
2514A 6 ti� ��� �.ft. ft. l
rL ft.
NC Well Contractor Certification Number vCG� O� =15.OUTER`CASING for,muld-eaied wb11s UR LINER'if a livable:_
N.W. Poole Well & Pump Co. ���''�p,' FROM TO DIAMETER ' THICKNESS MATERIAL
..� ft ft.
in.
Company Name J(C�`
\� t 16:1NNER;CASING OR TUBING ebthermal closed-loo '"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
) eothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT.
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD•&AMOUNT
Non-Water Supply Well: b ft. .7,00 ft. 4 t
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
ty 119R.OSAND/GRAOVEL'PACK if MATERIAL EMPLACEMENT❑Aquifer Storage and Recovery ❑Salim Barrier CEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL ING:LOG:attechadditional'ebeets..ifuecesa
❑Geothermal FROM TO DESCRIPTION color hardness solllroek type,grain a etc.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks O ft. • tt. a
4.Date Well(s)Completed: Well ID# Is ft. ft.
Sa.Well Location:
5,0 f ft. I ft. tIf
ft. ft.
Facility/O,,Ar l4ame Facility ID#(if applicable) ft. ft.
3�l(? AK t��N_ �2 lrf(�bw �oir� 71/l, ft rt.
Physical Address,,City,and ZilF ft. ft
OL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one
/lattlong is sufficient) 22.Certification:
N —7Ta Y6 f Cie.JI W D
�t
6.Is(are)the well(s): *ermanent or ❑Temporary Sign2e.fWdl Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or PRO 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this 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 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: _ 1 q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ (ft.)
For multiple wells list all depths ifdtTerent(example-3Qa 100'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
r
11.Borehole diameter: (� (in,) 246.For IDiection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: a« � 4r(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Sup ly and Open-Loop Geothermal Return Wells:Copy to the
county environments a epartmenvof a county ere ins
FOR WATER SUPPLY WELLS ONLY: k
24d.For Water Wells Producing overII00 000 GPD•Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018