GW1--05516_Well Construction - GW1_20230825

aVL'LL l.VIVDII(uu1rnp RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Nick Young •
Well Contractor Name FROM TO DESCRIPTION
4605-A 3 s-0 'ti 3 5- —" I f '
:SAP^-�
NC Well Contractor Certification Number ft R 1
FROM 1
OUT E'CASING(for multi-eased Wells)OR LINER(if op licable) , ,
N.W. Poole Well and Pump Co.
TO I DIAMETER THICKNESS MATERIAL
Company Name `'k• n• 1 4 5-ft. a ! in. I t N-S at 1 V
16.II NE -CASINGOR TUBING(Redtherinnl'closed-loop)2.Well Construction Permit#: `7/✓-/03/ SU' -Z O Z. 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) n. ft. 1 • 'a.
3.Well Use(check well use): n, rt. is -
Water Supply Well: 17:SCREEN
❑ r1CUlillral FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Municipal/Public - ff. it. in.
❑Geothermal(Heating/Cooling Supply) ISaidential Water Supply(single)
ft. n. In.
❑Industrial/Contmercial ❑Residential Water Supply(shared)
18.•GROUT • '
❑ln-igation ,❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z a r4
❑Monitoring '❑Recovery rt. `�
Injection Well: ft.
I
ft.
❑Aquifer Recharge ;❑Groundwater Remediation n
❑Aquifer Storage and Recovery !❑Salinity Barrier 19.-SAND/GRAVELPACK(If applicable) '•• : • , _ - _
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test '❑Stormwater Drainage rt. ft.
❑Experimental Technology `❑Subsidence Control ft. ft-
❑Geothermal(Closed Loop) 10Tracer 20.DRILLING.LOG(attach additional sheets If necessa
Return) ❑Other(explain under#21..Remarks) FROJ TO DESCRIPTION(color,hardnes;soIVroektype,grain Sill,etc.)
OGeothermal(Heating/Cooling • '
4.Date Well(s)Completed: C--7-23 Well ID# a ft. /00 ft C,c
I ci `Sat
Sa.Well Locution: /00 rt* 0 S ft l -r '""r
l
G
Facility/Owner Name Facility ID#(if applicable) ft. rt. •
AU U L J 2UZ3
Physical Address,City,and Zip rt. ft.
tom)Cl_ye_ 21.REtV1ARKS. ;;,
County Parcel Identification No.(PIN) Used steel hardened drive shoe
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(if well field,one lat/long is sufficient)
Q, �j �j 22.Certification:
1 139. 1/0)� N 7l/.7 S2 o W
e-y• 1 4000 .
i is
6.Is(are)the well(s): l lPermanent or ❑Temporary signs( a of • ell Contra,.r ! < Datc
By signing this form,I hereby car 1P that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ElNo 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a cow If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 1121 remarks section or on the back of this fora.
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-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 ;
6-
9.Total well depth below land surface: 0 S (ft.) Submit this GW-1 within 30 days For multiple wells list all depths if different(example-3@200'and 2@100') of well completion per the following:
10.Static water level below top of casing: 2_6 (ft 24a. For All Wells: Original form tI Division of Water Resources (DWR),
If water level is above casing use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6n fin) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Rotary Program,1636 MSC,Raleigh,NC 27699-1636 •
1
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le auger,rotary,cable,direct push,etc.) county environmental health department+of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 1100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ( Method of test:Blow Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: •
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
•
Revised 6-6-2018