GW1-2021-07173_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
Kevin Letchworth
Well Contractor Name
2514A
NC Well Contractor Certification Number
N.W. Poole Well & Pump Co.
Company Name 2
2. Well Construction Permit #: 353 7C5
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commerc ial
❑Irrigation
Non -Water Supply Well:
❑Monitoring
❑MunicipalPublic
esidential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells > 100,000 GPD
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: b 2 Y- 2
5a. Well Location:
/1-ff 8e.ido'1
Facility/Owner Name
.3i5 Socrec r».
Physical Address, City, and Zip
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
Facility ID# (if applicable)
I—re-tnklr'n(ze /l/G
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
%Al i N 1 Ut'] \t9®a W
6. Is(are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or
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.
.o
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
6os
For multiple wells list all depths if different (example- 3@200' and 1@100)
10. Static water level below top of casing: Z. v (ft)
If water level is above casing, use "+."
11. Borehole diameter: (in.)
12. Well construction method: 120"i t ii�
(ft)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
1/ 2
13a. Yield (gpm)
Method of test:
13b. Disinfection type: H l ! 1 Amount: i L b
W1-2021-07173
19
.14:;WATERZONES, [ , r':`
FROM
TO
DESCRIPTION
33 G) ft.
353 ft.
1/ 2 3'' '
ft.
ft.
°35.' OUTER CASING (for much-cased.wells);OR- LINER (if ap
Diable)... "
FROM
TO
DIAMETER
THICKNESS
MATERIAL
1 l ft.
L ft.
b in.-
li" t%
° c, (✓).Gc cJ
t�.16.rINNER CASING': OR. TUBING(gebthermal closed loop),..,
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17.SCREEN ..-. ' .. _ .
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
418:-.GROUT
,. t
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
G
2v
I�);��
f e) ''r
ft
ft
ft.
ft.
`,19, SAND/GRAVEL PACK (if applicable) , .
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
f4
:20.:DRILLING:
OG (attach additional sheets if necessary) ; x•
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain sizee
0 ft.
2 ft.
•—lj_,n . - C.
,
a ft.
3 ft.
�n
C/(CI t/
� ft.
�� ft.
y� v A (16 202\
ft.
ft.
Oc\�
ft.
ft.
p �10f''�
Isi
ft.
fL
'irti O'N �QC�,Gr
ft.
ft.
2L'REIVIARKS g .:4 - _.
Used hardened steel drive shoe
22. Certifica ' n:
tgnature of rtified We11 Contractor
6--
Date
ZI
By signing this form,' hereby certify that the well(s) was (were) constructed in accordance with
ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a copy
of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018