GW1-2021-07458_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: I
1.Well Contractor Information: 14� +
AND-).v _ '
;14:WATER":ZONES
Well Contractor Name , FROM TO DESCRIPTION
Oe ft. ft (c
NC Well Contractor Certification Number Co. rG Or `A&OUTER CASING for mull-cased wells OR LINER'if:a '"licable 'i.
N.W. Poole Well & PumpC 0� JF'J FROM TO DIAMETER THICKNESS MATERIAL
v� ��, 0'Lft.
j in. v
Company Name V (� ( J
//_ >.16.•INNER CASING°OR-TUBINVG a eotherm6l-clbsed=lod' _
2.Well Construction Permit#: (/—W G.�S /D L O FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits 6.e.UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fr. ft. in.
Water Supply Well:
❑Agricultural ❑MunicipaUPublic
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
Olrrijzation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 a. �dL�OG
❑Monitoring ❑Recovery fa ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑A uifer Storage and Recovery ❑Salini Barrier ,J9.eSAND/GRAV.ELPACK if.a Ilcable ':; ,
q g ry ty FROM TO MATERIAL EMPLACEM,ENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer =20:-DRILLING'LOG=ettachaddidonahsbeels'itnecess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness soillrock type,grain size,etc.
It. 2 fa 5-6 Q
4.Date Well(s)Completed: - C Well ID# IL
fL GjGt
5a.Well Location: ft.
.05".
4 — Sa U4�c a ft. ft.
Facility/Owner/Names Facility ID#(ifapplicable) / ft. ft.
�Z �1 /'- LV4 r ?) ,_ICr'; L 2 24 6 ft. ft.
Physical Address,City,and Zip ft. ft.
121"REMARKS.'
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees%minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certi eatio
N Po W
6.Is(are)the well(s): UfIrmanent or ❑Temporary ofCe ' Date
BY signing this form,I hereby certify that this well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8i 0 ISANCAC 02C.0100 or 15ANCAC 02C A200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under#21 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 construction info
construction,only 1 GW-I 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: z" (ft completion
For multiple wells list all depths ifd(aerent(example-3@200'and 2@100) ) Submit this GW-1 within 30 days Y of well P letion per the following:
10.Static water level below top of casing: (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use'•+' ) Information Processing Unit,1617 M`C,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 11A r Y 24c.For Water Supply and O en-Lf o Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental sal department a county ere ms e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine over-400.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: ""���y Permit Program,1611 MSC,Raleigh,�NC 27699-16 1 1
13b.Disinfection type: Amount: LG7
Form 6W-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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