GW1--05523_Well Construction - GW1_20230825

W Lt LL cupis'1 xucilON RECORD (GW-1) l For Internal Use only:
1.Well Contractor Information: j
Nick Young
14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4605-A 370 ft 3 Ts- ft SS(P,,,`
ft. rt. 1 .
NC Well Contractor Certification Number
15.OUTER-CASING(for°multi-cased•wehs)"ORLINER'(ifap licable)N.W. Poole Well and Pump Co. FROM TO�7 DIAMETER THICKNESS MATERIAL
Company Name t ( D• I
10 r ftI G I in. I •'�{'' U e t 1 V
q -16::INNERCASING OR TUBING(geother'malclosed;loop) -: F. si','
2.Well Construction Permit#: el Li — I t'J(TO^Z O Z 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. rt. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
❑ rcultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'� ❑Municipal/Public tt ft in.
❑Geothermal(Heating/Cooling Supply) residential esidential Water Supply(single)
n ft. _ in.
D1ndusirial/Commercial ❑Residential Water Supply(shared)
❑Inigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft
•❑Monitoring ❑Recovery ft Z d f4 IC'N t C l t—
Injection Well: ,
I
❑A uifer Reclrar a ft. ft.
q g ❑Groundwater Remediation
uifer Storage and Recovery 19:SAND/GRAVELPACKOfapplicable) :.'.,,
❑A
q g ry ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. IL
❑Experimental Technology OSubsidence Control rt. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(nttah-additjojjalisheet If necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solOrocktype grain size etc.)
//---�Z3 Gz %our' So.`
4.Date Well(s)Completed: CJ Well ID# a / s rt. Cl
ti
5a.Well Location: _( S ft.
(/U C n E
(Itpo ft ft i
AUG 2 2020
Facility/Owner Name Facility ID#(if applicable) f. ft.
(L( 7aiikAlAlleQ( kS L) q 1e,1 e r31,1 0 c ft. ft Inform/Am Pr::es►sakw Unit
Physical Address,City,and Zip ft R. laWCriwDG
W ..\CP 21rREMARKS
County Parcel Identification No.(PIN) Used steel hardened drive shoe
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
��.��� ®® ��,^n ��n 22.Certification: _-
rc�2 f7 W
6.Is(are)the well(s): LlPermanent or ❑Temporary Signat a of i�ell Contra:r 1 '% Date po
By signing this form,I hereby ce OP that theiwell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
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#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 td,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:
C/( 24.SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: �� ft.
For multiple wells list all depths if different(example-3 at 00'and 2@100� ( ) Submit this GW-1 Within 30 days of i ell completion per the following:
10.Static water level below top of casing: (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"-I-
11.Borehole diameter: 6" fin) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Rotary
1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ry 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(La 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 100,000 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:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018