GW1-2021-00872_Well Construction - GW1_20210818

WELL CONSTRUCTION RECORD
Form GW-1 Well Construction Electronic Form
North Carolina Department of EnvironmentalQuality
Division of Water Resources
July 1,2021
CONTACT INFORMATION
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Contact Name* Email Address`
Dustin Letchworth [e-mail]
Is this a revision to the form you have previously submitted?
Yes No
Please provide the ID#for the GW1 for that needs to be revised.
GW 1-2021-00799
WELL CONSTRUCTION INFORMATION
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1.Who is installing these wells?*
Owner Well Contractor
Please input your well contractor certification number to lookup your information.Once you have filled in the number,
hit the tab key to begin the lookup.
4367
1.Well Contractor Information:
Certificate# Cert Level First Name Last Name Company Name
4367 A DUSTIN LETCHWORTH Upfront Well Company of the
Carolinas
2.Well Construction Permit#:
354350-1
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA,etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal(Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
8/17/2021 50
(gallons per minute)"

5.Well Location
Facility/Owner Name*
Michael Keith Facility ID#
(Required) (If applicable)
County*
Franklin Parcel Identification No. (PIN)
Physical Address* Street Address
235 Sorrel Drive
Address Line 2
City State/Province/Region
Franklinton NC
Postal/Zip Code Country
27525 us
Latitude* 36.1116407000 Longitude*78.5100550000
Decimal degrees Decimal degrees
6.Is(are)the well(s):
Permanent Temporary
7.Is this a repair to an existing well:* Yes No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
145 surface?
For multiple wells list all depths if different 30
(example-3@200'and 2@100')
10.Static water level below top of casing: (ft.) 11. Borehole diameter:
60 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
50 13a. Method of test:
If applicable Blow
13b. Disinfection type:* 13b.Amount:*
HTH 1LB
14.WATER BEARING/FRACTURE ZONES
From To Description
130 135 50 GPM

15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 30.00 6.00 0.188 Galvanized
in feet in feet in inches
17.SCREEN
........................................................................................................................................
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 20.00 Holeplug Poured
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
........................................................................
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 20.00 Clay
in feet in feet
20.00 145.00 Granite
in feet in feet
21. Remarks
Used steel hardened drive shoe
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
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By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification's
,O&d&;r
Signature of Certified Well Contractor
Submittal Date 8/18/2021