GW1--05503_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only: 1‘...,--,..
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1.Well Contractor Information:
•David Massey I
14,WATER ZONES f
Well Contractor Name FROM TO DESCRIPTION
4591 - C fL ft. f
rL rt. i
,NC Well Contractor Certification Number
NW POOLE WELL & PUMP CO. 15.OUTER CASING(for multi-cased ivclls)OR LINER(if ap )?cable)
orlon° TO DIAMETER THICIOVE.SS MATERIAL
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• Company Name 0 fL 'Q ft. s� � m (^Gh y(t pVL �1►�+�
Gw Gq 3 q I`Z��3 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) n. rt. j In.
3.Well Use(check well use): rt. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE Tincl NE.Ss MATERIAL
Agricultural 0Municipal/Public 0 it fL in.
Geothemmal(Heating/Cooling Supply) AResidential)Water Supply(single)
fL ft. in,
industrial/Commercial 0Residential Water Supply(shared) -
18.GROUT
Irrigation FROM TO' MATERAAl. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. gi fL Ce i s.r+ Pout- Clgl N
Monitoring 0Recovcry fL f6
Injection Well:
Aquifer Recharge fL ft.
Groundwater Runediation
AquiferStorage and Recovery 19.SAND/GRAVEL PACK(If appltciubte)
OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage rt. fL
Experimental Technology 0Subsidence Control ft. fL
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(I-Icalina/Cooling Return) 0Other(explain under 1121 Remarks) FROM TO DESCRIPTION(color,hardness solVrock type.gun ales.etc.)
fL fL I'
i
4.Date Well(s)Completed: Well 1D# IL IL ; _
Sa.Well Location: • fL IL 1 R L�.�i V C I!J
Janine arke r+ it rL ' AIIG 2 5'2023
Facility/OsvnerName Facility(DIi(if applicable) fL fL
(3217 RA iSt.C1.6 Df• .Ru6ryh / l)C 2.7(91L fL IL trt,'C:t,ra:(cn Pr,;,*014r 1.°ty*
Physical Address,City,and Zip fL fL .
V3 CtICC. 21.REMARKS ,
s
County Parcel Identification No.(PIN) t I 1 U G i t\2✓ }a S}c„3 OT{t so r4es t-I tole..{cr
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: °' +f us%ov.,
(if well field,one llaa/lt/lojng is sufficient) �.j�q 22.Certification:J�.(6`I 1/ J N 7 (4 0/ 1 W
Permn:ment or OTemporaty Signature ofCertified Wall Contractor Date
6.Is(are)the well(s)
By signing this form,I hereby cert f/i•tmt,the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Ycs or DNo with 1SAA'CAC 02C.0100 or 1SANC..IC 02C.0200 Iiell Construction Standards and that a
If this is a repair,fill out known well construction ii/ornmtiona)td explain the nature of the copy of this record has been provided to the well owner.
repair antler 021 remarks section br on the back gfthis fort?).
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Gcoptobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needcxl. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS 1
•9.Total well depth'below land surface: Uh I(11ot-U'n (ft•) 24a. For All Wells: Submit this form within 30 days of completion of wall
For multiple wells list all depths ifdi,Qerent(example-3(a12.00''and 2gp100) construction to the following:
10.Static waterlevel below top of rasing: c2 (ft.) Division of Water Resourci s,.Information Processing Unit,
' water level is above casing.use"ff+__" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
•above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,,Raleigh,NC 27699-1636
13a.Yield(gpm) • - Method of test: 24c. For Water Supply& Infection Wells: It addition to sending the form to
the address(es) above, also submit oriel copy of this form within 30•days of
13b.Disinfection type: Amount: completion of well construction to th county health department of the county
where constructed. ;
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016