GW1-2022-07943_Well Construction - GW1_20220823

WELL CONSTRUCTION RECORD(GW-1) For Inlemal Use only:
I.Well Contractor Information:
Landon Phillips 14.WATER ZONES
Well Conimcior Name FROM TO I DESCRIPTION
3441 A ft. ft.
ft, It.
NC Well Contractor Certification Number 15.OUTER CASING for ni -cased wells OR L[NER if n, licnble
NW Poole Well and Pump Company rnDal TO DIAaI ETEII TUICICNESS alA1'ERIAL
R. rr. im.
Company Name .,
n J M ^O�1 16.INNER CASING OR TUBING cothcrmnl cl THICKNESS
2.Well Gnislruclion Permit q: (� �,/ I V� G"I -(i FROM TO DIAMETER TItICKNGSS MATERIAL
Lest fill applicable well concoction permits(i.e.UIC,County,State,Irariance,etc.) O ft-
3c,r ft- ( in,
3.Well Use(check well use): ft. ft. In
'Water Supply Well: 17.SCREEN
FRoNl TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public rt. ft, in.
❑Geothermal(1-1cating/Cooling Supply) ❑i6sidential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD rao5l I TO NATEIi1AL FRIPLACEMENT METHOD&AMOUNT
Noll-11'Mcl.Supply Well: ff. n.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
A. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(irnprdicabic
❑AquiferSloragcandRecovcry ❑Salinity Barrier FROai TO MATEIUAL I L•MPLACEaIENTNIETIIOD
❑Aquil'cr Test ❑Stonnwater Drainage ff 36 S f" Gr d1 I 200v_
ClExperimenlal•technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑''racer 20.DRILLING LOG attach addldonal sheets irnecessa
MotuTU DESCRIPTION color,hardness soilhock type, ruin sin etc.
❑Geolhennnl(Heating/CoolingReturn) ❑Other(explain under f121 Remarks) A ft
4.Dale Weli(s)Conglieled: r Well ID9
5a.Well Location: ft. ft.
r 11 (/ /p ft. ft.
I aci ily/Owner Nmne Facility IDN(iftipplicable) ft. ft.
V1.1 ICE r'?Aa l t?iT
Physical Address.City,and Zip ft. ft.
Ice-, It.REMARKS y J
County Parcel Identification No.(PIN)
if`'i fFYii3c,'rD:l Pr0�;wztdng UrW
5b.Latitude antd longitude in degrees/rninutes/seconds or decimal degrees: J.d
(irwcll field one hit/long is sufficient) 22.Cerlifieat'
M.I'toa N -7b1-1DID1 W 7-4-ate
6:Is(are)the well(s): Q01'ermanent or ❑Temporary Signature orCcniftcd Well Contractor Dile
UysigninS this brat,l hereby certify that the well(T)was(were)constructedin accordanrce with
7.Is this a repair to an existing Well: Oyes or i!nNo 13A NCAC 01C.0100 or 13A NCAC 01C.0100 111e//Consintction Standards and that a copy
!f'1his is a repair,fill out knout well construction h forniation and explain the nature of the of this record has been provided to the well ouvter.
repair under 1111 rentarks section or-on the back of dtis jinn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geolhernrnl Wells having die same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TO'rAL NUMBER of wells (add'See Ovcr'in Remarks Box).You may also attach additional pages if necessary.
drilled: 1 24,SUBI111TTAL INSTRUCTIONS
9.Total well dephh below land surface: 5- (r(') Submit this GW-I within 3U days afeell completion per the following:
nudtiple wells list all depths tfdlo&crit(example-3 rt 100'and 1 n 100')
241. For All Wells: Original form to Division or Water Resources (DWIZ),
10.Static water level below top of casing: C.) (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/Jli»rcr/crcl is abort casing,ore
11.Borehole diameter: G (in.) 24b.For Injection Wells: Copy to;DWR,Underground hljection Control(IUC)
Rotor Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well conslrucldou method: y 24c.For Water Supply and Open-Loop GeolbcrnwI Return Wells:Copy to the
(i.c.nugcr,rotary,cnblc,direct push,etc.) county enviromnental health department of the comely w lere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water WcIIs producdng over 100,000 GPD: Copy to DWR,CCPCUA
Blow Pennd Program,1611 MSC,Raleigh,NC 27699-IbI I
13n.field(gpnl) (' Method ortest:
HTH 1 lb.
13b.Disinfection type: Amount: j
i
Form GW I North Carolina Department of Environmental Qualify-Division of Wnler Resources Revised 6.6-2018