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Home My WebLink AboutGW1--02422_Well Construction - GW1_20240422 I WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: J : • 1.Well Contractor Information: '' i • Nick Young :. . • ='lic:viATERZONEs- . _ ,..�..i c?r�: ; _:-x.:. :_ FROM TO' DESCRIPTION• well ContrA rName. • A Sd R- o�'�R 4605- G2 / - ! NC Well Contractor CertificationNuinber 3Go ff. .�ur>ti ca. I N.W. Poole Well and Pump Co. IS.OUR TECASING(fo multi�ibiliwellsIORILINER-tifan-ucbler :,r: :" FROM TO DIAMETER . THICKNESS MATERIAL A I ft. ( ( m Co I`he. .lf? elaitA • Company Name :?16.INNERCASINTOR TUBING'Owithermateleiedthiop).a a4 t 2.Well Construction Permit#: t:-/tJ/qg3 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County,State,Variance,eta) R' R In. 3.Well Use(check well use): u' n' i Water Simply Well: P=17 SCREEN .._.. : r t"_.,:;i. . = ?'..-r =.Y w._.T- ..,- p y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ~ ❑Agricultural' . ❑MunicipallPiiblic ft. it. in. ❑Geothermat.(Heating/Cooling Supply) Agesidential Water Supply(single) m rt. In. • ❑Industrial/Commercial ❑Residential Water Supply(shared) "-±18:GROUT: d, . _, f s,x. . .•.: .; :' 1 -. ['Irrigation .. ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT- Non-Water Supply Well: (J it. CI.O it ' lobe e pair ' ❑Monitoring ❑Recovery ft. ft Injection Well: ft. It. ❑Aquifer Recharge ❑Groundwater Remediation 49:-SAND/GRAVELPACK(ifappl(cable)' - ' rn t- .r.4 afar r_i2 ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD °Aquifer Test ❑Stormwater Drainage ft. ' IL ❑Experimental Technology ❑Subsidence Control ft. ft. . 1 ' ❑Geothermal(Closed Loop) ❑Tracer -30:DRILLING OG,(ettncli addittunal"stieets"ifriecmnry)rr -r ['Geothermal(Heating/Cooling Return) ' ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,eowroekbva grave else,etc.) 0 IL 01 .n TonSotk 4.Date Well(s)Completed:3'-�I (f• Weil DM ft. cis" It. j / Sa.Well Location: G/ fc L!orft. 67reen i e r:-.., ,•a �1�.'s . ._. /� R, fL fl4 r (fah, ,� n AV it 2 2G"c Paoili wnerName Facility IDS(if applicable) .1 a4 ,Aat...A .l cm Cie Leir.4 JAG I, AC. ft n '3,7.4;v. ... U Physical Address,City,and Zip it. It ! t''6 f''Ci.5 040 roam e-i on . IVRF.MARKS'ks,:= h z r-Vi.,, i'd.i.M• 1•W. . .. :tv. .. zian°'t t.. County Parcel Identification No.(PIN) Used steel hardened drive shoe L Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) G 22.Certification: - f I, 3k.DL GS�+3 N — 1 S.1-t�os brit W 7/.04C::::7 3�'vI"a iSi a of '• ell Con Date 6.Is(are)the well(s): elPermmment or ❑Temporary 1 By signing this form,I hereby cet the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well:. ❑Yes or No 15A NCAC 02C.0100 or ISA 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 thisform 23.Site diagram or additional well details: &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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add See Ovet'in Remarks Box).You may also attach additional pages if necessary. drilled: / 24.SUBMITTAL INSTRUCTIONS' 9 Total well depth below land surface: gar (D') Submit this OW-1 within 30 days lof,well completion per the following: For multiple wells list all depths tl'dijjerent(example-3 a(�1 00'and 2Q100). I. 10.Static water level below top of casing: Z(3 kit') 24a. For All Wells: Original form j to Division of Water Resources (DWR), If water level is above casing use'o •• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 6" 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC) 11.Borehole diameter: (n•) Program,1636 MSC,Raleigh,NC 27699-1636 12.Well construction-method:Rotary (i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply,and Open-Loop Geothermal Return Wells:Copy to the county environmental health depart rent of the county where installed. FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produdng over 100 000 GPD:Copy to DWR,CCPCUA 13a.Yield(gun) 3 Method of test:Blow Pelmet 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