GW1-2021-07332_Well Construction - GW1_20211006

FELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
A.Well Contractor Information: � ® �3
Kevin Letchworth
im 9 0 � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2514A 0 6 2��1 a. fr.
lsS �O
NC Well Contractor Certification Number �egSU1g (So ft. ft. �
�+� pip., '15i`OUTER CASING for multi=tali" �el);`OR�LINER'if�e ticable a..c".
I .W. Poole Well & Pum�n(yl �<<orJA CJgG�,o� FROM ft TO it DIAMETE`Rtn THICKNESS MATERIAL
Company Name ff /�l j r/r r
A&INNER CASING.OR TU : e BINGot6e�mal closed loo
2.Well Construction Permit#: �0 QT-7O66 '�Z/ FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction per tits(I.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
1`!'hater Supply Well: 17:'SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. 7ft. t in. 24jS/
❑Geothermal(Heating/Cooling Supply) VResidential Water Supply(single) ft. ft. in. (•e
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT._.
❑Irrigation ❑Wel Is>100 000 GPD FROM TO MATERIAL EMPLACEMEM21ETHOD&AMOUNT
Non-Water Supply Well: ft. ft. L
i❑Monitoring ❑Recovery it. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
i;19:BAND/GRAVEUPACK if a' licable :i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage Q ft. tr. �
i❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.'DRILLING LOG.etlaeli additiouelsheets if beees5 E
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) —FROM TO DESCRIPTION color,hardness soil/rocktype,grain size,etc
d ft. / ft.
�C>( i'
Date Well(s)Completed: Zf] Well ID# ft. !fs rt. 4 3 i G✓,�
5,9.Wel ocation: y� I ft. � � ft. `
tfit q Uts/dJ tr. ft.
Facility/Owner Name
��� �' /7d�f/ Facility ID#(if applicable) ft. ft.
2W� F=e�z- A4rr�J ('y ft. ft.
Physic
/al
/A�dydrrreessss,City,and Zip f� �J ft. ft.
Al Gck- ff �0�_5&�2�? .21 REMARKS _.
^_.ounty Parcel Identification No.(PIN) Used hardened steel drive shoe
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lla 7
att/loon sufficient)
g is sucient) /� 22.Certifieatio/nn:
e��1 D I N "—]'6,'�V��� W
.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor D e
By signing this form,I hereby certify that the ivell(s)was(were)constructed In accordance with
Is this a repair to an existing well: ❑Yes or V0 15ANCAC 02C.0I00 or 15ANCAC 02C.0200 Well Construction Standards and that a copy
f(this is a repair,fill out Mrosvn well construction injormatlon and explain the nature of the of this record has been provided to the well ouvter.
epalr under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
3.For Geoprobe/DPT 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
?.Total well depth below land surface: � u� ({t,)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use'," u ) Information Processing Unit,1617 MSC;Raleigh,NC 27699-1617
11.Borehole diameter: & (in.) 24b.For Infection Wells: Copy to DWR,Underground Injection Control(IUC)
JJ Program,1636 MSC,Raleigh,NC 27699:1636
i2.Well construction method: a// N7a`'� �
24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental ealthdepartment of the county where costa Ie
i FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD: Copy to DWR,CCPCUA
S l Permit Program,1611 MSC,Ralei ,NC 27699-1611
I.3a.Yield(gpm) >/ Method of test: X(,tfi(i i
13b.Disinfection type: (40- Amount:
i
s orm GW.I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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