GW1-2020-00033_Well Construction - GW1_20200921

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WELL CONSTRUCTION RECORD
NORTH CAROLINA
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• Construction Electronic
North • Department of • - Quality
Divisionof • •
September2020
Submission ID# GW1-2020-00033
CONTACT INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
Contact Name* Kevin Letchworth
Email Address* office@nwpoolev,ell.com
This will be used to email you a copyof the submitted form.
WELL CONSTRUCTION INFORMATION
................................................................................................................................. .................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Well Contractor Name NC Well Contractor Certification#* Company Name
Grant Mason 4254A NW Poole Well and Pump Co.
2.Well Construction Permit#:
D-035237
List all applicable well construction permits(i.e.Monitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Water Supply Well
r Non-Water Supply Well
3.Water Supply Well* r Agricultural/Irrigation f Geothermal(Heating/Cooling Supply)
r Industrial/Commercial r Irrigation
r Municipal/Public/Community r Residential Water Supply(single)
r Residential Water Supply(shared) r Wells> 100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
9/21/2020 15
(gallons per minute)"
5.Well Location
Facility/Owner Name* Olde Heritage Bldrs.

Facility ID# (If applicable)
County*
Franklin
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2. above.
Parcel Identification No. (PIN)
Physical Address* Street Address
5610 Old US Hwy 64
Address Line 2
City State/Province/Region
Zebulon NC
Postal/Zip Code Country
27597 USA
Latitude* Longitude*
35534671.000000 78140715.000000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent f Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)Plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.)
164
For multiple wells list all depths if different(example-3 200'and 2@100')
9a.What is the depth of the casing from ground
surface?
108
in inches
10.Static water level below top of casing:(ft.)
20
If water level is above casing,use
11. Borehole diameter: 6
in inches
12.Well construction method:
r Auger r Air Rotary
r Cable Tool r Direct Push
r Mud Rotary C Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield (gpm)
15 13a. Method of test:
If applicable blow
13b. Disinfection type:* 13b.Amount:*
granular HTH 1 lb.
..................
14.WATER BEARING/FRACTURE ZONES
................ ................................................................................................................
From To Description
120 123 15 gpm
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
................................................................................................................................................................................
To From Diameter Thickness Material
0 107 6 .188 galv
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
in feet in feet in inches
18.GROUT
................
From To Material Emplacment Method&Amount
0 20 bentonite pour
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0 2 topsoil
in feet in feet
2 100 clay
in feet in feet
100 164 granite
in feet in feet
21.Remarks
Hardened drive shoe used on the bottom of the casing.
22.Site diagram or additional well details:

You mayupload additional well construction information here.
pdf only
23.Certification
Signature of Certified Well Contractor
Submittal Date 9/21/2020