GW1--05792_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 /75- f /-o ft S
370ft- 37s-ft. ?
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
N.W. Poole Well and Pump Co. FROM TO DIAMETER THICKNESS
/
MATERIAL
Corn an Name t l it l� it G2 in. 1/6 7 (7et )V
P Y
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (7)�///6' -ZG Z Z 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 it in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public it ft in
❑Geothermal(Heating/Cooling Supply) chttfesidential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: G ft. a G ft a eft ron 1 e p ---
❑Monitoring ❑Recovery it ft.
Injection Well:
ft. n.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) •
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft R
❑Experimental Technology OSubsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additionni sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under l 21 Remarks) FROM TO DESCRIPTION(color,hardness,soWrock type,grain size etc.)
ft U Z tGp Sot
4. Date Well(s)Completed: 7-/ 7-2_3 Well ID# 2 ' c/o it S(.tc cif C
5a.Well Location: C/U ft (/Or rL ('1r-1, t I( •,�^.
•'a..- .1..-,
r i/ rt. R. ([
Facility/Owner Name{� Facility ID/4(if applicable) a. n- J`P ? 2024
Physical Address,City,and Zip 2. 7 C -7 n. n-
7{Gt/1‘G`.14-(1
/ 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)
. fC1 � N -M,4 1 6 5 22.Certificationb :
W
7- 17 -Z3
6.Is(are)the well(s): t Permanent or DTemporary Signal a of ell Contra r Date
By signing this form.I hereby ce Or 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 114 NCAC 02C.0290 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 to provide additional well construction info
construction,only I 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: 6/QC (f(•) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Z rJ (f1) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing use"+"
11.Borehole diameter: 61 (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) / 7 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