GW1-2021-07339_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Landon Phillips
14.WATER ZONES
Well Contractor Name Tp w FROM TO DESCRIPTI N
3441A �C� 6 1.s0\9vr�t oo ft. 305 ft. f /k
re / ft. C < ft.
NC Well Contractor Certification Number 9C0 :,On Sr/o `, J
,���Or CJ.g,Gti' 15:OUTERCASING for`miilh-cas :we11s.ORLINER ifs" `Gceble'i
N.W. Poole Well & Pum�g� ;P11 FROM TO DIAMETER THICKNESS MATERIAL
Company Name UU tYJ
ft. 178 ft i in. I(iflvj �
(�I�� I (} "M INNER CASING OR, ING' 'eothermal closed-loo
2.Well Construction Permit#: J / r-t ( `1 w FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '.17 SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
S76
dustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT z-?
❑Irrl ation ❑Wells>100,000 GPD FROM TO ATERIAL EMP CEMENT METHOD&AMOUNT
Non-Water Supply Well: v ft. 'oft. '
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'"SAND/GRAVEL'PACK ifs `ncable ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer :30.DRILLING LUG attmhadditi6ualsheets if uecessa `_`
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillrock rains etc.
rt. � ft.
4.Date Well(s)Completed: — `Z Well ID# ca ft. ft. y
5a.Well Location: -7 ft'
-70
8
1ctn�n C1'�c_ Detle(okt ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ro P—C rt y L✓C/( -3 ft. ft.
Physical Address,
City,and Zip ft. ft.
-
County Parcel Identification No.(PIN) Used hardened steel drive shoe
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onteelat/long is sufficient) ` 22.Certif o
lsu
t711 N (�G 1 it
W 7- 13 Z
6.Is(are)the well(s): V4rmanent or ❑Temporary Sier, Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or p4Vo 15A NCAC 01C.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 ofthe 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: /O! (ft,)
For multiple wells list all depths it different(example-3@200''�,and 2@100) Submit this GW-1 within 30 days of well 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),
Ifwater level is above casing,use"+" ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-]617
11.Borehole diameter: (in,) 24b.For Injection Wells: Copy to D, Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 276994636
12.Well construction method:
(i.e.auger,rot 24c.For Water Supply and O en-Loo Geothermal Return Wells:Copy to the
g rotary,cable,direct push etc.) county environments health epartment 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:
Io Li Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
'r '
L
13b.Disinfection type: TrL Amount: '
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources k Revised 6-6-2018
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