GW1--02379_Well Construction - GW1_20240423

\\'ELL CONSTRUCTION REC'OR1)((;W-1) kw Metm,I Uw tiny f
J 7 1
1.Well Contractor Information: - -- - CI J
Nick Young 14.WATER EMUS
FROM III t lama serum
R'cll 001111.toi Name
4605-A )(es A. d5( it -3 5 PA,Ni.'Well Oiinti actin Collin lin,Xiindri ,
IS.OUTER CASINO(for multi cased walk)OR LINER(If apptk.ltle)
N.W. Poole Well and Pump Co. FRuaI uI it AME1Fa_ tine from LMAIFRUt
i.•m(•nm Nome
-- (`) FLl,(Cl 1 n. fi 11 In. , / 5- I i GC ( �
16.INNER CASING OR TURING b(ealhnm.l dosed-
2.Well Construction Permit 9: FROM in DIAMETER rmcanns i ;MAFRRUI._
tart all err+tnuMe...;1 o•tiro-n,»..t crate.I'm,awir,,a,) IL rt. It•
1' Iv^rnnrty .e.(!li,t'.vnnt.
3.Well toe(cheek well use): n. n. in
Water Sappy Well: 17.SCREEN -
FROM TO DIAMEI ER SLOt SIZE I1IICKME19 1 MAT KRIM,
(3.1gn ulturnl °Municipal/Ptlhlic n. R. In.
❑(wtiwthurnal(I1eating'Ctx'ling Suppi).) ) - e%identinl Water Supply(single) R ti in -� ---� -
Olndustrial'Commxc nl /❑Residential Water Supply(shared) la.GROUT
,CIrrit lion ❑Wells?100.000(il'!) FROM TO MATEWA!. F-MPLACEMF,`I I.METRO!)d A MOmIT
Non-Water Supply Well: n- !L
0Monitoring. ❑Recover' R ft.
Injection Well: '
R R
°.Aquifer Recharge °Groundwater Retlodiation
uifer Storage and Recov'cry ❑Salinity Barrier 19.SAND/GRAVEL PACK(if appllohlc)
❑A
q g FROM TO atATERLt1 rsar1.ACraiMr ME.TmryD
°:Aquifer Test ❑Stormwater Drainage n. ft.
GExpetimental Technology °Subsidence Control R R
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING l.OG(attach additional sheets If necessary)
❑Carothecmnl(Heating/Cooling Return) DOther(explain under 921 Rsnnaics) FROM To DESCRIPTION(color,hard.,5 ern vcY err grain a e.nr-,
vs"- 30c-n• 6-4,„fe
4.Date\i'ell(s)Completed:(c'-2I-23 Well Ma n. R
511.Well Location: It R
r._.�
R R l, .i, t,1 L,)
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Facility:Ow•ner Name Facility IDS(if applicable) R R 1!
R 2
/O SG,c 17,t,jrs.ILI /21/r/�/esrt /1( ft It L��4
Physical Address.City.and Zip R- n- '' -;.'ti'4i", 'ti'..1.:t.:21.REMAR KS J
County Parcel Identification Nn(PIN)
Used steel hardened drive shoe
5b.Latitude and longitude in degraxslnnni es/seconds or decimal degrees:
(if wall field,one tat/long u sufficient) 22.Certification:
3S-F'g32 N - -1 8-IgY3 W
6.Is(are)the weU(s): OPetmfncnt or ❑Temporary Squat c a: ell Coma r Date
By signing this form,1 hereby cc rr that the well(s)was(were]constructed rn accordance with
7.Is this a repair to an existing well: ❑Yes or t No ISA NCAC 02.0.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and arplarn the wtirc of the of this record has been provided to the well owner
repmr under.21 remarks section or on the back of this form
23.Site diagram or additional well details:
&For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well const:ueti.;n info
construction,only i GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if neczs.itrw
drilled: _ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 5 (It.) Submit this G W-1 within 30 days of well completion per the followUn2.
For multiple wells list all depths afdrp'renu(example-3©200'and?Q100')
24u. For All Wells: Original forni to Division of Water Reo ure.S JAR%
10.Static water level below top of casing: C' (ft•) lnfommation Processing Unit,1617 MSC,Raleigh.NC 27690-161'
If water few!is above casing use"-"
6" 24b. For inlection Wells:Copy to DWR,Underground Inix:ion Control(II C
11.Borehole dlanrter: (la) Program,1636 MSC.Raleigh,NC 27699-163o
12.Well construction method: 24c-For Water Sappy and Open-Loop Geothermal thrum\tells:Cops'c•
L a eager,cowry.cable,duvet push,etc.) county environmental health department of the county what installed
POI(WATER SUPPLY WELLS ONLY: tad For Water Wells producing over llkl 0110 GPI):i.;av to i)R tR, l't'i l +.
Udsird Blow Permit Program,161I sl5C.Ital.teh,NC 27'69Llo'.!
13a.Yield(gpm) Method of test:
1 I36. i:Ilion type:HTH Amount:
rani.';i!-I Ilolth r'arohn]Deparuneul of Envuanmeutal Quality-Div talon,4'Water-itca.uuve. .... .-.a .