GW1--05789_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
•Nick Young 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4605-A 1(U n. /C'S /0
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of ap licable)
N.W. Poole Well and Pump Co. FROM TO DIAMETER THICKNESS MATERIAL
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Company Name 4- `/ a �� ft. (o in I / O 7 `zc `"(
16.INNER CASING OR TUBING Geothermal closed-loop)
2.Well Construction Permit#: FROM -TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(y e. UIC,County,State, Variance,etc.) ft. in
3.Well Use(check well use): tI rt in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural MunicipaUPublic ft. ft in.
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n. n, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS GROUT
❑Imgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: O fL a U n. ge)j„-1t it
e- a m/�
❑Monitoring ❑Recovery n. n. [fL P t
Injection Well:
ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage rt. rc
❑Experimental Technology ❑Subsidence Control IL f.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,mwrcektrpe Praia sirs etc.)
4.Date Well(s)Completed: 7 Well ID# a n- I CI rc r
5a.Well Location: !Q a ,A0r it 6/4nt to t 17-
7-7--.
6 I Mailer 464405 ZZ.0
Facility/Owner Name Facility ID#(if applicable) rt. n .�t-I b V [Q�4
M� // R R
Physical Address,City,and Zip it. n
?fan /t��-/f 4 21.REMARKS
County Parcel Identification No.(PIN) Used steel hardened drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
``�� 2 22.Certification: � ,�
3L . VO I-1 51 N - 7 . 5-15 'J W `��,,i4C) 7•2? 3
6.Is(are)the well(s): ClPerntanent or OTemporary
Signal a of eft Contrac�r Date
By signing this form,1 hereby ce tfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or inNo 15A NCAC 02C.0100 or 15A 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 421 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-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
9.Total well depth below land surface: O))LC S_ ft.
For multiple wells list all depths ifdrfJerent(example-3 a�00'and 2@I0o') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z 0 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
60
11.Borehole diameter: (in) 24b. For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Rotary Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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) SO 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 f 6-2018