GW1--05791_Well Construction - GW1_20240926

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Joshua Garrett Bradshaw 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4512-C RS ft 145 ff. 5nual ,•vr:f t r
ns ft ft '1 `� i{ r
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
NW Poole Well and Pump Company FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft _ ft id pvc liner
I,` /(Q l_ �'1 0�1'2 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W V-I lO O i {.J FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.(AC,County,State.Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ©MunicipavPublic ft. ft is.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
QlndustriaUCommercial EjResidential Water Supply(shared) Ig,GROUT
^I Irrigation FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
Monitoring QRecovery ft ft.
Injection Well: ft ft
0 Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ©salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage it it.
DExperi.mental Technology QSubsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gam sae,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft ft
4.Date Well(s)Completed: 5/16 Well iD# ft ft ; -
5a.Well Location: ft. ft ► ./ 4......4
DAArt. P e-rt wife, ft. ft S E P 2 0 2014
Facility/Owner Name Faci�litty iD#(if applicable) ft ft
LoZ f►,�
y te10$S g0lf. Zeb4/0, 1 piC -21 19 7 ft ft _ :tr.; -w '.i>
Physical Address,City,and Zip ft ft
Franklin 21.REMARKS
County Parcel Identification No.(PiN) Installed a liner boot to seal off surface water.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification:
35.-rRe71 t.,
N - 78 . 32b5'i ' W i.„..........._,......„.
6.Is(are)the well(s)OPermanent or OTemporary tore of Certified Well Contractor D
By signing this form,I hereby cern&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f3 Yes or DND with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction Information and explain the nature of the copy of this record has been provided to the well owner.
repair under'2I 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 site details or well
construction,only 1 GW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: rr�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10(a 2 (ft.) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple wells list all depths if different(example-3 and 2@I00') construction to the following:
10.Static water level below top of casing: -y (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
construction to the fallowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Supply& injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016