GW1--02381_Well Construction - GW1_20240423

WELL L COrSTRIICi'ION RECORD((;\V-I) lot Inland Ibe•i),tiq -
1.\\ell l'on(tnetor inforntation: ' f
Nick Young
14.WATER ZONES
Well ionnarlo�\isle. IROM Ill nra[RRttir "-_ -_
4605-A L!'a2 n• /37 n 1-0 _ _..
1.7o R. 113- R 1 a
NC\1'dl ions soar(nutindten\uudvy IS.OUTER CASING(for huff+ aced well.)OR I.LYP.R Df ap aea ti -
FROM
N.W. Poole Well and Pump Co, FRO rn t DIA.N/.1FR m RSY i el �F WATrR1A1. _
co,,,,,,,,�',mc ---- ----- 1".( ft 1(5--.�n. G In. I .1 V tA.V
/� "�
16.iNNER C'ASIN(_OR h IKINI:(grnthnmal rtex!-I.rp)_____-
2.Reil Construction Permit q: C 00,3�7 l a. FROM In n AtAMETER T)nrK llTh NATPRIAL"---- -
;.1st ail appi:.rthl.-veil rrnstrurnon permits pee.llh'.County,State,Variance,neta I R• n. In.
3.Well Use tcheek well use):
n. n. In.
Water Supply Ne1L: VI.Sl'xKI-N
FROM ill Dot MFl K ER %MI stir Ill r wArrgAt.
C Igoe:ultra al ❑N luniapatiPubl tc tL in
C� 1S5'� �l .Zr .,eery i PVC„
CCszothcxmal(HeatingCooling Supply) f sidential Water Supply(single) rt. IL In
°Industrial Commaeial ❑Residential Water Supply(shared) tK.GROUT
Clrieatiotl ❑\Yells>100.0(10 GPD FROM TO MATERIAL EMPLACEMFNl%%mon A Astr nNT
Non-Water Supply Well: O rt.
a�O R .f!_ L_� r
❑Vtonitonng °Recovery a 9 i L7r T�f
Injection\\ell: R fL -
CAquifer Recharge ❑Groundwater Remediation -
19.SAND/GRAVEL PACK(if appliablt)
CAquifcr Storage and Recovery ❑Salinity Banner FROM TO MATERIAL EMPIACF i iT ME71IOD
°Aquifer Text CSlormnater[Drainage 0 it I gl$-R• #3 PX1' _
❑ExpeimnttalTechnology ❑Subsidence Control n. IL
❑Geothe mal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheen If nerevarv)
FROM TO DFSCRIPTIO�la,ttardurra.,lire:4 type,Frain du,et.-t
CGeot ermal(Ileatine/Cooling Rclum) °Other(explain under 1)21 Ranars) O
r^un R d it ?OP Sett)
-- __
J.Date Well(s)Completed: -�Orof 4 Well IDtt a R q a-
e a d . ' '1
5a.Well Location: Cl t.. ft /If r1z (57Gs�'-e. Y +� i._ ,:
(Alt /'(Qmf /Ion 2 IL t- r.
FacilityOwner Name /� Facilityc ID(if applicable)
/ it. It � Ltl��
`/a'lo old/1/ /f I
2d. l ele//,S40 /1 - R R '. v:,.y J>?
Physical Address,Cuy,and Zip 2 R '.
_Qj�\/ 21.REMARKS
County Parcel Identification No(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Lao long is sufficient) .22,Certification:
35--$L2c4, to N -- • c Cr,0o2 w 6:7,______
-co -a(6.ls(arc)the well(s): l Permanent or ❑Temporary Signor c of dl Coaet7 rDate
By signing this forme I hereby cer(iJf t that the well(s)was(vereI eonatructed in axonitnce..tth
7.Is this a repair to an existing well: ❑Yes or d No 15.4 NCAC 02C.0100 or 1 SA,VCAC 02C.0200 Well Construction Stmsdvds and that a cop.
lido is a repair,fill out known well constracaan tnformanon and explain the nature of the of tins record has Goan provided to the well owner.
repose under n2/remarks section or on the back of this form.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute You may use the back or this page to provider additional cell construction info
construction,only 1 GW-1 is needed. Indicate TOTAL.NURiBER of Hells (add See Ova'm Remarks Box).You may also attach additional pages if tea wry
dnlluic 24.SUBMITTAL INSTRUCTIONS
/ Q
9.Total well depth below land surface: [ O T (R)
For multiple wells list all depths if different(example-3C2o0'and 2@,100') Submit this G\Y-1 within 30 days of well completion per the following:
Z.O rt. 24a. For All Wells: Original form to Division of Water Resources WW1(
Static water feud below top or casing: ( ) Information Processing Unit,1617 MSC,kahaeh.NC 27699-161'
If water level is above casing tune•'+"
n
11.Borehole diameter: 6 (in) 24b.For Injection Wells:Copy to DR,Cndauotmd injection Con!vl ill t..
Program,1636 MSC.Raleigh,NC 2 7 699-1636
Rotary
12.Well construction method: 24e.Fur Water Supply.and Open-Loop Gtothernttnl Return\tells:Copy to t
(I a auger,rotary,cable.direct push,etc) county enviromlRTtol health dep,utment of the tieing where utsullal
FOB WATER SUPPLY WELLS ONLY: 24d.For Water Wells mducirtb user II0t.I)(t talk Coos to i)1\k �t Fw't
13a.Yield(gpm)
z_a ltettrodtlltest:Blow PsamttProgram.It,l1 MSC,Ralec.ih NC 7-e,•/,t-Intl
HTH
13b.l)islnfectiun type: Amount:
1.•:rts,T,N North Carolina Dcpanneent of Iluvuotunental Quality-LNvuu.n of W it.-s ftei.nnss. 4 ea.rat es-w-