GW1--05800_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Infornmtion:
Nick Young
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14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4605-A 2%0 ft• AO- It I O
It it
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wella.19R LINER Of ap licable)
N.W. Poole Well and Pump Co. . FROM TO DIAMETER THICKNESS MATERIAL
1-1 rL �Xi to In. ./e 7 (Li 7 aiv.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 7 6' P�3 r// FROM TO DIAMETER THICKNESS MATERIAL
R ft in
List all applicable well construction permits(Le.UIC.COL .State,Variance,etc.)
-
it. ft. in
3.Well Use(check well use): -
17 Well: FROM SCREEN
Water Supply
TO DIAMETER ShOI"SIZE THICKNESS MATERIAL
CI Agricultural ❑Municipal/Public rt. n. In.
❑Geothermal(Heating/Cooling Supply) ipigesidential Water Supply(single) ft. n, In.
❑lndustriaVCommercial ❑Residential Water Supply(shared) is.GROUT
❑irigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it g•O Is. 13seev#Ort1[a- pot-)T
❑Mon itoring ❑Recovery It It
Injection Well:
ft 1L
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomtwater Drainage R It
❑Experimental Technology ❑Subsidence Control m rt.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTIOM�,Ior,hardaesb soil/rock rock type,grain sloe,etc.)
❑Geothermal(Heating/Cooling Return) ❑Oilier(explain under#21 Remarks)
2 U It a ft. i opt_0o I
4.Date Well(s)Completed:G-3 c2 11 Well ID# a n' a� n- *q�L / J
5a.Well Location: d S ft ()Lis". (4,j( /S14 C
C24/ey LAncf rtsl/t i
ft n i l�.t.a a,-. . S4 1...�.0
Facility/Owner Name Facility EON(if applicable) ft. 11-
(0q-t:Jl„ - c p ea( i 43bro 'NC_ rt. ft. CEP n 2024
Physical Address,City,and Zip n. n' Ir40:-.r.4,i 'I• .
/^ 1 L„ • 21.REMARKS
Lowly T�C•� Parcei Identification No (PIN) Used steel hardened drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat./long is sufficient) 22.Certification:
3"� . c) ('-c_11S N iot, 15-(L'lP0 / W !)' 7
,^Jp-.2 4
6.Is(are)the well(s): nPermanent or 0 Temporary Signal c of ell con ra ,r Date
By signing this form I hereby ce Or that the%ell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or it No 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 421 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3®200'and 2@i 00')
0 (it)
i 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: el ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use",-"
6" 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: pa)
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
Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 C, Method of test:
13b.Disinfection type:HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018