GW1--05478_Well Construction - GW1_20230821

VVIJLL Lu fllS1KUC'I'1ON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nick Young
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4605-A • 37 -rt• 3 it \
NC Well Contractor Certification Number ft. ft. �I�I.�
15.OUTER CASING(for'multj.cnsedlwells)OR LINER'if up livable) -' •• • , .
N.W. Poole Well and Pump Co.
FROM I TO I DIAMETER I I THICKNESS MATERIAL
Company Name I- 1 n (-(/ ft. CO
lin' t / �� (-r I v
` 7 16.INNER CASING OR TUBING(geothermal'cl/osed-loop) •'. •`2.Well Construction Permit it: 1 CJ 7/6) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) ft. f4 In.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN . • ,
❑ cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public fL ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
❑Industrial/Commercial / fi ft. to
❑Residential Water Supply(shared)
❑Irriga$on 18.GROUT _ .
❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
U ft. 1 / ft. l" n 4 k hoc,r-
❑Monitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifef Storage and Recovery ❑Salinity Barrier191 SAND/GRAVEL PACK(if applicable) -. - •---. --
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It ft.
❑Experimental Technology ❑Subsidence Control p, ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary): - ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness wWrocktype grain sire etc.)
/ O it
ft
4.Date Well(s)Completed:to_d_Z 3 Well Mil c IL i. S ft r, l C,
5a.Well Location: el S-ft 6 0C-11 Y 7cE r
ft.
ft.
Facility/Owner Na�ntme Facility Off(if applicable) 11 (( ff ft. ft. AUG 2 1 2023
/12 ( S l ` �,�� 11 1 n 1`I �1 ft ft `
r�5►ycr\ L1i�GRC�� l�lY�✓t 11 QC !`�cJ i b +A ien Pf^i:T GtYia L its
Physical Address,City,and Zip 21 5(.171
7Z n, D:QI3OG
cAci a-//G,7/ 1✓V! 21.REMARKS
County Parcel Identification No.(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one ladlong is sufficient) 22.Certification:
CI 0 5q/1- N 7q).61 B16o w �,.
� 6-z-z. 3
6.Is(are)the well(s): ClPerm►nent or ❑Temporary Signal a of e1lContra r Date
By signing this form,I hereby ce ify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or elNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this 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.
repair under tf21 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
9.Total well depth below land surface: G 0 (ft.) completion of well
days
Submit this GW-1 within 30
For multiple wells list all depths if different(example-3®200'and 2@100') per the following:
10.Static water level below top of casing: Z a ft, 24a. For All Wells: Original fonn to Division of Water Resources (DWR),
If water level is above casing use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" fin) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636 •
12.Well construction method: 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 of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gp m) I Method of test:Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:HTH Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018