GW1--02382_Well Construction - GW1_20240423

WELL CONSTRUCTION RECORD(GW-1) I•or Internal!kr(MINI-
P.-
1.Well Contractor intii,ntttinn:
—
Nick Young 14,RATER,utrv_S
FROM 10 ' U[S(.RIP ION
Well.enuacter Name
4605-A a7f• ntfo
R tt-
Nl'welt:.nuacnrt:nviisatu,r+Numha 15.O(rrE.R('ASINC(tic multi cased_ell!OR iINT.R r• ticshIej
N.W. Poole Well and Pump Co. lRO31 110 ` MAMMA ritujRctFS7 N�A.rr^RIAL
,l 1'1 n' Yj` a 1 CO In. .1 O 7 1 `. iti.k vr
:nmrany Nome _
1 Ri.INNER CASING ORTTMINGtgrrmnlclmed-MoV) _ _. _.
2.Well Comtruction Permit//: CC MM
,,1.3 DO ILIA, E1
t FROM ,TO DI.%MFR Firm.Miss r n1ATERI 1. .-—
i.rat all applied*well cnnsnvcnon pe m is P.c.Ulf.C..mnn•.Site.l'armiwo,etc 1 n' N' In.— --
R ft. in
3.Well Use(check well use): —
Water Su 17.SCREEN
Well: lNOM r0 DIAMF'I FN NI Of SIr.E IRtcX7+PST I MA MAIM.
IAgricuilural ❑Municipal/Public it. A. in.
°Geothemal(Beating/Cooling Supply) IAA sidcntial%Vara Supply(single) A. R In. T
I G"ndustrial Commercial / Rcsidential Water Supply(shared) 'IS.GROUT
❑Irrieation ❑Wells' 100.000GPD FROM TO MAT FRUf. AMFI.MFMINT MF.iROD&AMOt7at
Non-Water Supply Well; V it 0 R 1 cif i you r-
cMotitoring ❑Rlxovery R ft. (-_
Injection Well:
R R
CAquifix Recharge ❑Groundunter Remedial ion
19.SAND/GRAVEL I'ACK Or applicable)
❑Aquifer Storage and Recovery °SalinityBarner 1110M TO ' MATERIAL EMPIACEMENT.MFTR/O
°Aquifer Test ❑Stoma ater Drainage R R
DExpein aital Technology °Subsidence Control R ft.
CC,eolhsrnal(Closed i-oop) ❑Tracer 20.DRILLING LOG(attach additions!sheets!Totes-tsars)
Cnothemtal(Heating-Cooling Return) ❑Other(explain under 1121 Remarks) FROM ro D6eruPTtory(cater.harass.,nw a+qP..train s><.+e
77 f' 0 R 1 R To So,l
0.Date 1\'c11(s)Completed: '1'a'[ Well IN , R SO R C Iy/ &S'Ard •,
Su.Well Location: SSo a' .5((,S'R "lean 'ey
i9-be1 �Ileao R R 4Pv 2 iota
-acibt)iOwner Name Facility IDS(if applicable) IL ft.
SO 3I r_itri.J Rd '&I1`y nC R R '•-;-..k:; r '-,,,A
Physical Address,City,and Zip ft. R ''�• j
/A) Sh 21.REMARKS
Countya Parcel Idcnufcatmn No.TIN) Used steel hardened drive shoe '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(:f well field one lavlong is sufficient) •22.Cer86ctdon:
35.77{( N --- 1g'b9o°) W
6.Is(are)the well(s): �.Pcrnuncnt or °Ternporvey Signet c of ell Contra r Date
By signing this form!hereby cc ify that the well(s)was(were/constructed in accordLrr-e wan
7.Is this a repair to an existing well: °Yes or ±No I SA NCAC 02C.0100 or 1 SA,VCAC 02C.0200 Nell Catstrrcnon Statdvds and that a cam
1 ra 5 is a repair.fill out known well construction information and splam the nature of the of this record her been provided to the an outer.
repair under.121 ramarkr 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 bock of this page to provide additional tell consauction into
construction,only 1 GW-1 is needed. Indicate TOTAL.WMBER of wells (add'See Over'in Remits Box).You may also attach additional paves if nccessar-
driilod: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: SW (f4) Submit this G\Y-1 within 30 days of well completion per the follow u
For multiple wells list all depths of tbffereni(example-3(arr00'and 2@l0') y P4''
ZO at) 242. For All Wells: Original form to Division of Water Resaxicces (OUR). .
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC:76)')-1617 l
/f water level is above casing use"-,"
6" 24bb For Injection Wells:Copy to DWI(.Undavround ht)xuon C•nnrci(1L"C
11.Borehole diameter: On) Program,1636 MSC,Raleigh.NC 27699-1636
12.Well construction method:Rotary 24c.1-or SS'ater Supply and Open-i.twp Ccuthrrttul Retutn Wells:Copy to tft,
h c auger,rosary,tulle,anent push.etc.) county environmental liuilth Jg urtment of the count!.who.:instal-xi
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells ppnsducInra aver 11111,1100(:PII:Ca pv DN"R,i t't Y't t
BlowPunta Pt°gram,InI1 MSC.Raleigh.NC_..nr3.1.,I I
Liu.Yield(gym) Method of test:
HTH
lilt.Disinfection type: Amount:
North Carolina Depsnmeta of Etivunnnscmrl Quality-Uiynian of\value k.,,.w._s